William Gray — PFD report 2023-0511

Date of report	8 Dec 2023
Reference	2023-0511
Deceased	William Gray
Coroner	Sonia Hayes
Coroner area	Essex
Category	Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths
Organisation named	Mid and South Essex NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	6

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Chief Executive Officer Mid & South Essex NHS Foundation Trust
Chief Executive Association of Ambulance Chief
2.

Executives

3.

Chief Executive East of England Ambulance Service NHS

Trust

4. Victoria Atkins Secretary of State for Health
5.

Chief Executive Officer Essex Partnership University

NHS Foundation Trust

1

2

3

4

CORONER

I am Sonia Hayes, Area Coroner, for the coroner area of Essex

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

INVESTIGATION and INQUEST

On 9 June 2021 an investigation was commenced into the death of WILLIAM BRIAN
KIN GRAY age 10. The investigation concluded at the end of the inquest on 22
November 2023. The conclusion of the inquest was 1a Cardiac Arrest Secondary to
Respiratory Arrest 1b Acute Asthma Secondary to Chronically Very Under controlled
Asthma.

William Gray died as a consequence of failures by healthcare professionals to recognise
the severity and frequency of his asthma symptomatology and the consequential risk to
his life that was obvious. 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.

CIRCUMSTANCES OF THE DEATH

William had a seven-year history of asthma and met the criteria for specialist referral.
William’s care and treatment was sub-optimal; his asthma was poorly controlled in the
absence of appropriate assessment and reviews. William required chest compressions
and intramuscular adrenalin in accordance with the Joint Royal Colleges Ambulances

1

Liaison Committee (JRCALC) Guidelines with oxygen for a life-threatening asthma
attack on 27 October 2020 that saved his life. William was conveyed to Southend
Hospital where he was discharged home four hours later with no assessment of his
recent symptomatology and no change to his medications. Family contacted the GP
service for advice and chased a referral to the asthma and allergy services. No changes
were made to William’s medication until 4 November 2020 when he was prescribed a
steroid preventer inhaler at the request of the asthma nurse and follow-up with Southend
Hospital. William was lost to follow-up at Southend Hospital following a consultant
appointment on 14 November 2020. The Asthma and Allergy Service comprised of
telephone calls of no more than five minutes with no contact after 1 February 2021 until
21 May. The GP prescribed four short doses of oral steroids for exacerbations of his
asthma in December 2020, February, April and 19 May 2021 that were insufficient to
effectively manage obviously poorly controlled asthma in a picture of vastly excessive
reliever inhaler prescriptions and the absence ongoing of preventer medication.
On 21 May 2021 the asthma nurse did not review or escalate the increased salbutamol
inhaler use information shared. The advanced GP nurse practitioner reviewed William’s
condition on 25 May 2021 at the request of the GP following the final prescription of
steroids and confirmed that William’s asthma remained very poorly controlled but failed
to escalate concerns. As a consequence of multiple failures, William suffered an
inevitable life-threatening asthma attack on the night of 29 May 2021 and crew arrived at
approximately 00:18. Ambulance Crew could not secure William’s airway when he went
into respiratory arrest with a missed opportunity by ambulance crew to administer
intramuscular adrenalin in the presence of a strong pulse that probably would have
delayed the cardiac arrest and possibly saved his life. William went into cardiac arrest at
approximately 00:35 with further crew on scene and chest compressions commenced.
Intravenous adrenalin was administered at approximately 00:45 when William was in the
ambulance and resuscitation continued until HEMS met the ambulance en-route to
hospital. The HEMS doctor inserted an endotracheal tube and administered medications
and William was conveyed to hospital. William had sustained a brain injury not
compatible with life.

5

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action
is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. –

Mid & South Essex NHS Foundation Trust

(1) Experienced hospital paediatric doctors all gave evidence that they were unaware
that administration of intramuscular adrenaline by paramedics is part of the Joint Royal
Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma.
The beneficial effects of the administration adrenalin was not considered, William’s
presentation on arrival at hospital was falsely reassuring.

Association of Ambulance Chief Executives

(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics
and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets
out treatment for it, however as paramedics rarely attend:

a. Clarity is required on what should be catagorised as a life-threatening asthma. With
guidance to enter the algorithm immediately to administer intramuscular adrenalin
the purpose being to avoid cardiac arrest. Paramedics are more familiar with
administration of intravenous adrenalin during resuscitation once cardiac arrest has

2

occurred

b. does not contain clear guidance or advice on what to do when crew cannot

ventilate, cannot oxygenate, or

c. when to abort repeated unsuccessful attempts to secure an airway and progress to

hospital

inflation pressure being a potential cause of failure to secure a paediatric airway

d.
adjunct in life threatening asthma the consequence of this being increased
ventilations pressure would be required

East Of England NHS Ambulance Trust

(3) Learning and sharing lessons learned is a function of investigation. The Trust
investigation report did not:

(a) scrutinise the ambulance attendance to William on 27 October 2020 in
comparison to the attendance on 29 May 2021 and missed an opportunity to
understand:

i.

the importance of the administration of adrenalin during a life-threatening
asthma attack in accordance with the JRCALC guidelines and that there
may be additional training needs. Two paramedics attended both on 27
October 2020 and 29 May 2021 but did not consider the administration of
intramuscular adrenalin on the second occasion.

ii. Whilst life-threatening asthma in children is an extremely rare call, the same
two paramedics attended on 27 October and 29 May and initial treatment
given differed during a life-threatening asthma attack

iii.

iv.

that ambulance crew focused on the airway to exclusion of other treatment
options and did not recognise the significant amount of inflation pressures
that are required to manage the airway of an asthmatic child in respiratory
arrest. Crew were misled in thinking that the airway adjunct equipment was
not the correct size as a consequence, and were swapping the adjuncts

that the same paramedic was left managing an airway throughout the arrest
despite the arrival of more experienced colleagues that arrived as backup,
including an LMO until HEMS took over.

The Trust did not address the issues at 3 (a) i-iv above in their annual training following
William’s death and no alerts or learning notes have been circulated.

(b) East of England Ambulance NHS Trust investigation did not identify a number of
risks and omissions its investigation of this child death:

i. inflation pressure being a potential cause of failure to secure a paediatric airway
adjunct in life threatening asthma the consequence of this being increased
ventilations pressure would be required

ii. Intramuscular adrenalin was not administered for life threatening asthma for a
child in respiratory arrest in accordance with JRCALC

iii. Intravenous adrenalin was not given or attempted when the patient went into
cardiac arrest in accordance with the resuscitation guidelines and Intraosseous
access was not attempted for a child in cardiac arrest for at least 10 minutes
and only when the patient was in the ambulance.

(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must

3

not insert endotracheal tubes as a safety measure to avoid adverse incidents as there
was a difficulty in keeping paramedics skills up to a level of competency. Evidence was
heard that the Trust has since revised its policy and reintroduced endotracheal
intubation for a specialist cohort of paramedic crew:

i. The Trust treatment for those aged 12 and over permits endotracheal intubation
by those ambulance crew with specialist qualifications however, they cannot
intubate children under 12 who are entirely reliant on HEMS arriving in sufficient
time if the airway cannot be sufficiently managed.

ii. Essex is a large county and there are very few paramedics trained on any one
shift to provide endotracheal intubation

there is a difference in provision of life-saving treatment in Essex between those

iii.
over 12 and for children under 12 and HEMS is a charity with very limited
resource across a very large county.

Secretary of State for Health

(5) Training for health professionals who care for children and young people is not
mandatory

The National Capabilities Framework for Professionals who care for Children and
Young People with Asthma (NHS Health Education England) contains tiers of training
and national capabilities but is not mandatory and although it sets out in the ‘Forward’ to
that document that:

“The UK has some of the highest prevalence, emergency admission and death rates for
childhood asthma in Europe and outcomes are worse for children and young people
living in the most deprived areas. A number of reports produced in recent years make key
recommendations for all professionals involved in the care of children and young people with
asthma. The National Review of Asthma Deaths and the more recent Healthcare Safety
Investigation Branch report highlight the need for healthcare professionals to be competent in
the management of children and young people with asthma.
The development and implementation of the National Capabilities Framework for Professionals
who care for Children and Young people with Asthma, aims to ensure that all professionals
involved in their care are meeting the level of competency required for their particular role in
the management of that child or young person. The adoption of this framework will ensure that
competent professionals are delivering effective asthma care and will therefore drive
improvements in health outcomes for children and young people with asthma, as well as
education and training in the future.”

and in the ‘Background’ to the document

“ …One successful contact with a well-trained professional may be the contact that makes the
difference.”

Essex University Partnerships NHS Foundation Trust

(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)

a. At the time of William’s initial referral to the Service in 2018 this consisted of one
nurse for approximately 2000 children, and this increased to two nurses in November
2020. The evidence heard is that whilst the number of nurses has increased so has the
geographical area that the Service covers, and that there are ongoing plans to increase
this further. The Service remains under resourced whilst attempting to expand.

b. The Service continued to operate during the pandemic and did not introduce video
calls when they could not make face-to-face attendances. There was no risk
assessment of the impact on the Service, and no audit of whether this was sufficient to
manage the Service. There is no contingency plan in place should this issue arise again.

4

c. The Service relied on telephone contact Nurses did not speak to William although he
was old enough to be involved in his care.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you
and your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by Monday 5th February 2024. I, the coroner, may extend the
period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise, you must explain why no action is
proposed.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:

•
• Care Quality Commission

(Mother)

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the coroner, at the time of your response, about the release or the publication of
your response by the Chief Coroner.

6

7

8

9

8 December 2023

HM Area Coroner for Essex Sonia Hayes

5

Responses

6 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Association of Ambulance Chief Executives (PDF)

Association of Ambulance Chief Executives
25 Farringdon Street
London
EC4A 4AB

30 January 2024

HM Area Coroner for Essex
Sonia Hayes

Dear Ms Hayes

WILLIAM GRAY (DECEASED)

I am writing in response to the preventing future deaths report we received at the Association of
Ambulance Chief Executives (AACE) dated 8th December 2023, and I respond as the Director of
Operational Development and Quality Improvement on behalf of the AACE. On behalf of AACE, I would
also like to extend our sincere condolences to the family of William.

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh NHS
ambulance services. Its purpose is to support its members, UK NHS ambulance services, in the
implementation of national agreed policy and to act as an interface, where appropriate at a national level,
between them and their stakeholders. It is a company owned by NHS organisations and possesses the
intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance
service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or
instruct ambulance services however it has national influence via the regular meetings of ambulance chief
executives and chairs along with a network of national specialist sub-groups.

With regard to your matter of concern relating to ambulance services:

Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the
Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out
treatment for it, however as paramedics rarely attend:

a. Clarity is required on what should be categorised as a life-threatening asthma. With
guidance to enter the algorithm immediately to administer intramuscular adrenalin the
purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of
intravenous adrenalin during resuscitation once cardiac arrest has occurred.’

b .Does not contain clear guidance or advice on what to do when crew cannot ventilate,
cannot oxygenate.

c. or when to abort repeated unsuccessful attempts to secure an airway and progress to
hospital

d. Inflation pressure being a potential cause of failure to secure a paediatric airway adjunct
in life threatening asthma the consequence of this being increased ventilations pressure
would be required.

1

Thank you for bringing these tragic circumstances to our attention and allowing us to consider how our own
guidance might be improved. The JRCALC guidelines are advisory and have been developed to assist
paramedics make decisions about the management of the patient’s condition , including treatments and to
support clinical practice.

The advice is intended to support the clinician’s decision-making process and is not a substitute for sound
clinical judgement. We recognise that the guidelines cannot always contain all the information necessary
for determining appropriate care and cannot address all individual situations; therefore, we expect that
paramedics using JRCALC guidelines ensure they have the appropriate knowledge and skills to enable
suitable interpretation. JRCALC guidance is not intended to be a full medical textbook, and therefore
underpinning knowledge around conditions such as asthma is expected, and this should include an
understanding of the pathophysiology of asthma and how the condition affects the airways.

JRCALC provides specific guidance for asthma in adults and children. Many of the guidelines contain key
points, and included in the key points in the asthma guidance are:

• Asthma is a common life-threatening condition.
•
Its severity is often not recognised.
• A silent chest is a pre-terminal sign.
• Bronchodilators are the mainstay of treatment.
•
• Clinical assessment should determine the severity of the asthma attack.
• Consider magnesium in life-threatening asthma not improving with continuous nebulised

Ipatropium bromide should be considered in severe cases.

salbutamol.

• Consider adrenaline for life-threatening asthma continuing to deteriorate with continuous nebulised

salbutamol.

The guideline highlights that that there should be a specific assessment of the severity of the asthma
attack and contains a table describing the features of severity. It also contains an algorithm detailing how to
manage an asthma attack depending on the severity. It does also detail when to consider administering
adrenaline.

At the JRCALC committee meeting on 9th January 2024 we discussed this preventing future deaths report
as an agenda item. A decision was made to undertake a review of the guideline and particularly the
assessment and management algorithm and decide if it can be made clearer and have more detail and
emphasis on the use of adrenaline.

With regard to airway management, the JRCALC guidelines provide guidance in the resuscitation sections
on managing an airway and using a stepwise approach including considering when to progress from one
airway technique to another. As you will be aware, airway management is a practical skill and needs
regular training and practice which is beyond the scope of JRCALC to mandate. It is for the individual
clinicians and the organisation that they work for to ensure the competency of airway skills and agree
which advanced airway skills and airway adjuncts should be used. In managing a difficult airway such as in
the case of life threatening or near fatal asthma, part of the training of a paramedic would be to understand
the potential difficulties that may be encountered and the strategies that may need to be considered in
each individual case. This includes decisions about calling for enhanced help and urgent transport to
definitive care.

We are aware that most ambulance services do not support intubation by all paramedics. We know that it
is a skill used by some paramedics, mainly where they have received additional training and are able to
maintain their competency. Our guidance states in relation to tracheal intubation:

2

The tracheal tube is a challenging airway device to insert successfully and requires both
adequate initial training and ongoing practice. Paramedics must ensure that they have
appropriate competence to undertake it safely and that this skill has been regularly updated
and evidenced through maintaining an airway skills log.
There is no evidence that patient outcome is any better following tracheal intubation
compared with any other type of airway.
Where, as a paramedic, the governance system you work within allows you to intubate, you
should only do so if you have maintained your skills and have evidence of self-audit with a
success rate of greater than 95% success rate within two attempts.

In the advanced life support (ALS) for children guidance it states:

During ALS, the priority remains the delivery of high-quality chest compressions and effective
ventilations with high-flow oxygen. Particular focus should be to ensure reversal of any
hypoxia.

Supraglottic airways (SGAs) may be considered if BVM (bag valve mask) ventilation is
ineffective.

Intubation is rarely indicated and should only be undertaken by those with appropriate skills,
according to local protocols and only when waveform capnography is available.

In summary, we have reviewed our JRCALC guidance in relation to the matters of concern you have raised
and will now review the asthma guideline and make changes if these are deemed to be required. We will
also share the details of your concerns with our national ambulance service medical directors’ group
(NASMeD). They have regular meetings where learning from incidents and preventing future death reports
are discussed. We will suggest that medical directors of the UK ambulance services consider if they
believe any further education or awareness is needed for their clinicians, in relation to airway management
and asthma and particularly in relation to considering administering adrenaline in asthma.

I hope this response has adequately addressed the concerns that you have raised. If you have any further
questions, please do not hesitate to get in touch.

Yours sincerely

Director of Operational Development and Quality Improvement

3

Response from Department of Health and Social Care (PDF)

Andrew Stephenson MP
Minister of State

39 Victoria Street
London
SW1H 0EU

19th February 2024

Ms Sonia Hayes,

HM Area Coroner for Essex,

Ground floor
Seax House
Essex County Council
Victoria Road South
Chelmsford
CM1 1LX

Dear Ms Hayes,

Thank you for your letter of 11 December 2023 about the death of William Brian Kin
Gray. I am replying as Minister with responsibility for education and training of the
NHS workforce.

Firstly, I would like to say how saddened I was to read of the circumstances of William
Gray’s death and I offer my sincere condolences to the family and loved ones. The
circumstances your report describes are very concerning and I am grateful to you for
bringing these matters to my attention.

Employers in the health system are responsible for ensuring that their staff are trained
to the required standards to deliver appropriate treatment for patients and for ensuring
that staff have appropriate time to undertake continuous professional development.
Health Education England (now part of NHS England) published The National
Capabilities Framework for Professionals who care for Children and Young People
with Asthma with a range of training programmes for people to use.

The Framework is aimed at anybody who may encounter a child or young person with
asthma, including healthcare professionals. As you note, it sets out a range of
capabilities, which can be achieved for most of the tiers through structured education
programmes. Individuals working at tiers 4 and 5 may choose to complete a portfolio
of evidence instead. Several national courses have been designed and accredited to
meet the capabilities for tiers 1 to 4.

In general terms, the standard of training for health care professionals is the
responsibility of the health care independent statutory regulatory bodies who set the
outcome standards expected at undergraduate level and approve courses and
Higher Education Institutions to write and teach the curricula content that enables
their students to meet the regulators outcome standards. The Health and Care
Professions Council and Nursing and Midwifery Council are the regulators for
paramedics and nurses respectively.

Whilst not all curricula may necessarily highlight a specific condition, they all
nevertheless emphasise the skills and approaches a Health Care Practitioner must
develop in order to ensure accurate and timely diagnoses and treatment plans for
their patients, including for asthma.

UK medical schools determine the content of their own curricula. The delivery of
these undergraduate curricula have to meet the standards set by the General
Medical Council (GMC), who then monitor and check to make sure that these
standards are maintained. The standards require the curriculum to be formed in a
way that allows all medical students to meet the GMC’s Outcomes for Graduates by
the time they complete their medical degree, which describe knowledge, skills and
behaviour they have to show as newly registered doctors.

The curricula for postgraduate specialty training is set by the Academy of Medical
Royal Colleges for foundation training, and by individual Royal Colleges and faculties
for specialty training. The GMC approves curricula and assessment systems for
each training programme. Curricula emphasise the skills and approaches that a
doctor must develop in order to ensure accurate and timely diagnoses and treatment
plans for their patients.

Employers in the health system are responsible for ensuring that their staff are
trained to the required standards to deliver appropriate treatment for patients.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Kind regards,

THE RT HON ANDREW STEPHENSON CBE MP
MINISTER OF STATE

Response from East of England Ambulance Service (PDF)

'•'1:kj

East of England
Ambulance Service
NHS Trust

East of England Ambulance Service NHS Trust
Wh iting Way
Melbourn
Cambridgeshire
SG86NA

HM Coroner Sonia Hayes
Area Coroner for Essex
By email

29 January 2024

Dear Ms Hayes

I am writing further to the inquest into the death of William Brian Kin Gray, which concluded on
22 November 2023. I understand that you heard evidence from a number of Trust witnesses
during the inquest. Following this you made a Regulation 28 Preventing Future Death report on 8
December 2023 outlining your concerns and I have responded to these below:

Learning and sharing
investigation report did not:

lessons

learned

is a function of investigation. The Trust

(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison

to the attendance on 29 May 2021 and missed an opportunity to understand:

i.

the importance of the administration of adrenalin during a life-threatening
asthma attack in accordance with the JRCALC guidelines and that there may be
additional training needs. Two paramedics attended both on 27 October 2020
and 29 May 2021 but did not consider the administration of intramuscular
adrenalin on the second occasion.

ii. Whilst life-threatening asthma in children is an extremely rare call , the same two
paramedics attended on 27 October and 29 May and initial treatment given
differed during a life-threatening asthma attack.

It was clear from the evidence given at the inquest and from the crew's previous attendance to
this patient that adrenaline could have been administered to William in accordance with the
JRCALC guidelines. The crew were aware of the guidelines and this is not disputed. It was a
challenging and busy scene and this contributed to the crew omitting to administer adrenaline.

The Trust has completed work over the past year in relation to human factors and how these
influence behaviour at work in a way which can affect safety. Posters have been disseminated
across the region and pop-up banners are being used at engagement events across the Trust.
The Patient Safety Team have also included information around human factors in the Safety
Matters Newsletter, which is a monthly publication shared with all staff, and released a podcast
last year on human factors . There are two training modules available to staff, which have been
publicised as well.

In order to raise further awareness, a case study will be included in the Safety Matters Newsletter
and the Trust's pharmacist will include information around the benefits of IM adrenaline being
administered to a patient with life-threatening asthma together with the appropriate point to
administer this. The aim is to demonstrate to staff the physiological benefits of administering in
this situation .

Chief Executive:
Chair: Mrundal Sisodia
www.c'<-stamL .nhs.uk

#WeAreEEAST

For adult patients, the Trust used to have access to pre-filled IM adrenaline syringes and a report
will be taken to the Trust's Medicines Management Group for consideration. Paediatric patients
are not administered with a set dose and the clinician needs to draw this up separately dependant
on age/weight in line with JRCALC guidance.

iii.

That the ambulance crew focused on the airway to exclusion of other treatment
options and did not recognise the significant amount of inflation pressures that
are required to manage the airway of an asthmatic child in respiratory arrest.
Crew were misled in thinking that the airway adjunct equipment was not the
correct size as a consequence and were swapping the adjuncts.

Information pertaining to the difficulties securing airways for asthmatic patients will be shared in
the Safety Matters newsletter as part of the case study. The Trust has also contacted the
Asthma and Lungs UK charity to establish if we could undertake shared learning or work with
them to produce further resources for our staff.

iv.

that the same paramedic was left managing an airway throughout the arrest
despite the arrival of more experienced colleagues that arrived as backup,
including a Local Operations Manager until HEMS took over.

Attendance to a paediatric asthma attack that leads to cardiac arrest is very rare for ambulance
clinicians to experience. A handover should be undertaken when new clinicians are arriving on
scene and this is the responsibility of both parties to engage in line with human factor training. A
case study of our attendance to William will be included in the Safety Matters newsletter, which
will include further inform_ation relating to the importance of handover communication when new
clinicians arrive on scene.

The Trust did not address the issues at 3 (a) i-iv above in their annual training following
William's death and no alerts or learning notes have been circulated.

(b) East of England Ambulance NHS Trust investigation did not identify a number of
risks and omissions in its investigation of this child death:

i. inflation pressure being a potential cause of failure to secure a paediatric airway

adjunct in life threatening asthma the consequence of this being increased
ventilations pressure would be required

ii. Intramuscular adrenalin was not administered for life threatening asthma for a

child in respiratory arrest in accordance with JRCALC

iii. Intravenous adrenalin was not given or attempted when the patient went into

cardiac arrest in accordance with the resuscitation guidelines and lntraosseous
access was not attempted for a child in cardiac arrest for at least 10 minutes
and only when the patient was in the ambulance.

The Trust has recently recruited six Resuscitation Officers across the region. Part of their role is
to improve our response to critically unwell patients by designing a new cardiac arrest training
programme and provide coaching to clinicians. The delay in administering IV adrenaline and
gaining intraosseous access has been brought to their attention and will be included as part of
this updated training .
Chief Executive:
Chair: Mrundal Sisodia
www.€astan,L .nhs.uk

#WeAreEEAST

In terms of i) and iii), I have set out the actions the Trust is taking above.

(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must
not insert endotracheal tubes as a safety measure to avoid adverse incidents as there
was a difficulty in keeping paramedics skills up to a level of competency. Evidence was
heard that the Trust has since revised its policy and reintroduced endotracheal
intubation for a specialist cohort of paramedic crew:

i.

The Trust treatment for those aged 12 and over permits endotracheal intubation

by those ambulance crew with specialist qualifications however, they cannot
intubate children under 12 who are entirely reliant on HEMS arriving in sufficient
time if the airway cannot be sufficiently managed.

ii.

Essex is a large county and there are very few paramedics trained on any one

shift to provide endotracheal intubation

iii.

there is a difference in provision of life-saving treatment in Essex between
those over 12 and for children under 12 and HEMS is a charity with very limited

resource across a very large county.

There is strong scientific evidence that endotracheal intubation, like any skill, requires regular
exposure and practice to ensure proficiency in those moments when it is needed and there is
evidence of poor success rates without regular exposure and practice. On average, research has
shown that the average paramedic may be required to intubate an adult patient between 1-3 times
a year. It has also shown that the need to intubate a child is even less than that and is about once
every three to four years. These numbers are not sufficient to maintain competency and the skill
was removed for patient safety reasons. This is in line with other NHS Ambulance Services across
the country. The majority of airways in both adults and children can be managed without
intubation but by the use of a Supraglottic airway.

Currently Specialist Paramedic/Advanced Paramedic/Consultant Paramedic roles in Critical Care
and HEMS teams are authorised to intubate patients below the age of 12 in the East of England.
There are plans to introduce Advanced Paramedics in Critical Care cars across the region, one
per Integrated Care Board area, as part of the advanced practice program roll out.

Your report also referred to the Serious Incident investigation and missed opportunities for
learning. Since this investigation, the Trust has implemented the Patient Safety Improvement
Response Framework, which was produced by NHS England and sets out the approach to
developing effective patient safety systems and learning from these incidents. The approval
process for identifying actions from patient safety incidents is now more robust in that an Action
Setting Group meets fortnightly to review incident reports and set appropriate actions.

I hope this provides you with assurance in relation to the actions the Trust is taking in relation to
this sad event and I am happy to provide a further update on these actions in the coming months.
Please do not hesitate to contact me should you require any further information.

Chief Executive
Chief Executive:
Chair: Mrundal Sisodia
www.(astamb .nhs.uk

#WeAreEEAST

Response from Essex Partnership University NHS Foundation Trust 1 (PDF)

02 February 2024

Private and Confidential
Ms Sonia Hayes
HM Area Coroner for Essex Coroner’s Office
Seax House
Victoria Road
Chelmsford
CM1 1QH

Chief Executive Office
The Lodge
Lodge Approach
Wickford
Essex
SS11 7XX

Dear Ms Hayes

Master William Brian Kin Gray (RIP)

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule
5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013, dated 8th December 2023 in respect of the above, which
was issued following the inquest into the death of William Gray (RIP) .

I would like to begin by extending my deepest condolences to William Gray’s family. The Trust
sympathises with their very sad loss of their young child.

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed
and noted. I will now respond in full to these concerns in the hope that this provides both
yourself and William Gray’s family with comprehensive assurance of changes that have been
made at the Trust to address the concerns you have raised.

Concern a) The Asthma & Allergy Children’s and Young Persons Service (the Service), at the
time of William’s initial referral to the Service in 2018 this consisted of one nurse for
approximately 2000 children, and this increased to two nurses in November 2020. The
evidence heard is that whilst the number of nurses has increased so has the geographical area
that the Service covers, and that there are ongoing plans to increase this further. The Service
remains under resourced whilst attempting to expand.

Response:
We agree that there were demand and capacity challenges in the service which the Trust has
raised with local commissioning bodies over time to try to resolve. This matter was first raised
in 2018 and continues to be discussed with the local Integrated Care Board.

The Trust has noted the valid concerns raised by the family as well as the Court in terms of
resource, and has again reflected on service need and the required resources in order to meet
demand.

In line with the evidence presented as part of this Inquest, the Trust had a 1.0 whole time
equivalent (wte) Band 6 in post at the time of the incident to deliver a community specialist
asthma and allergy service. The role had a large caseload, however the remit was narrower

than it is currently. The role provided telephone review assessments, face to face initial patient
assessments in local clinics, attendance at multi- disciplinary meetings and Asthma and
Anaphylaxis training and education to local school nurses and health visitors, as well as in
preschool nursery settings.

In 2018 EPUT co-hosted a South East Essex Children Asthma and Allergy system-wide
workshop where the benefits realised by the limited service was widely recognised.

The Commissioners agreed to support the development of a business case for additional
investment. The service reviewed the national models of good practice and with the support of
the Commissioner, prepared a business case for additional investment into the existing
service. Unfortunately due to the Covid pandemic, this was delayed as the Commissioners
were redeployed to alternative roles. Subsequently, an opportunity arose to apply to NHS
England for pilot monies to expand the integration into primary care networks and to promote
the ‘Asthma Friendly Schools Initiative’. The business case prepared for the expansion of the
existing team at the previously co-hosted workshop was submitted to NHS England requesting
an additional 8.0 wte Band 6s to deliver an enhanced service in South East Essex. In 2021 the
service was awarded an additional 3.0 wte Band 6s to deliver a pilot in local surgeries and to
implement the Asthma Friendly Schools Initiative. Whilst the Trust was not awarded the full
application of 8.0 wte, we were able to recruit to 3 further roles which has had a positive effect
on service delivery.

The service continually endeavours to work hard to improve and deliver a responsive service
to those who are referred to the Asthma and Allergy Service for support. Service provisions
and compliance is monitored to ensure we continue to maintain a responsive service. Further,
children are safety netted via signposting to GP’s and charities such as Asthma + Lung UK and
Allergy UK.

Since 2018 the service has seen an increase in the complexity of need in the local population
and observed challenges for patients and parents accessing timely support from both primary
and secondary care. In collaboration with the Commissioner and Secondary Care, the service
has responded to system pressures by upskilling our nurses in non-medical prescribing, Tier 4
Asthma training and Association for Respiratory Technology & Physiology (ARTP) accredited
Spirometry training. This has afforded the service users the option of opting to access the
service more frequently as it is more accessible- for example for prescriptions, preventative
inhalers, and spirometry assessments and for support to progress secondary care referrals.

In light of the service increasing its levels of expertise, it was viewed as a one stop shop for all
types of requests from minor to urgent, however, the service now has clearer communication
pathways for responsibility of care according to clinical need.

Whilst the total patient caseload has remained similar to previous years the number of patient
contacts (face to face and non-face to face contacts) has increased substantially -by 75.5% in
2023 compared to 2018. The service strives to remain accessible but to maintain a safe and
efficient level of service provision, a review of the existing support issued by the ICB has been
commenced.

The above detail is set out in an effort to demonstrate to the Court, the acknowledgment that
greater support is required in relation to demand, and the plans in place to address this.

It is of note that the geographical boundaries of the area remains the same but the population
has grown and the referral volume has increased by 75%.

Due to the close working relationship between the Service and the ICB and the ideas
generated for service development, NHS England has awarded monies to develop and
implement the following:

• The Asthma Friendly Schools training to educational staff to ensure safety of children and

young people within school.

• To upskill the GP practice nurses and enhance the GP’s knowledge regarding evidenced

based medicine management,

• Direct patient care will continue to be delivered and remain in South East Essex only.

The service developed an internal service development plan and a project group with the full
engagement and support of the ICB Commissioner, who has also been advised of the content
of this Regulation 28 Report.

The clinical lead nurses attend the bi-monthly Mid and South Essex Asthma and Allergy
Network meetings (which includes attendance by the MSFT Specialist Consultant Clinical Lead
and the Primary Care Networks Clinical Lead) to engage and collaboratively work together to
deliver more joined up care and develop clarity and understanding of functions. The team
participates in the East of England Asthma network comprising of a number of expert
multidisciplinary professionals in the speciality of asthma who share best practice and ideas for
further service development.

Prior to this Inquest, the service had already recognised improvements were required to
effectively and safely improve the efficacy of clinical practice and continues to do so on a daily
basis:

• Reviewing the service eligibility criteria
• Partnership working with the integrated care system to ensure the service remit is

understood to be a supportive specialist service and not an urgent /emergency service.
This remains the remit of primary and secondary care.
• Reviewing the SOP and Service Business Continuity Plan
• Reviewing the care pathway with partners
• Remodelling the community specialist asthma service offer – with engagement from

system partners so there is greater clarity on roles and functions of all

• Review of the assessment templates and proforma documents to ensure equity and
consistency of the assessments undertaken and the documentation recorded.

• Review care plans, symptom management plans, and letter templates
• Reviewing the eligibility of the respiratory caseload
• Review of the rag rating criteria of the Amber/Red/black critical caseloads to ensure the
correct process of the next steps are identified i.e. once stable referral back to primary
care (Amber). If remains uncontrolled, despite supportive management, onwards
escalation and referral to secondary care (red) and tertiary care (black critical

• The Service holds clinical supervision once a month.
• The Service holds Difficult Asthma Meetings with the secondary care team every 3

months and a monthly Difficult Asthma Meeting within our team.

• Difficult Asthma Clinic held once a month at the hospital between the service and

Secondary care team

• Continued good relationship with Secondary Care team who supports our service in

•

caring for the patients
Implemented the use of video conferencing (AccuRx) to visually perform remote
assessment, although please note this does not afford the opportunity to perform chest
auscultation which would indicate the presence of wheeze. This method of virtual
assessment can demonstrate the teaching of peak flow and inhaler technique and enable

assessment.

• Timetable of clinics encompassing face to face assessments, AccruRx and telephone

review assessments.

• Dedicated appointments times pre-booked in advance to ensure parent/carer/ patient

response uptake

• We are working closely with our Commissioners at MSE ICB to continue to seek

opportunities for additional resources whilst transforming the service within current staffing
capacity.

Concern b) The Service continued to operate during the pandemic and did not introduce video
calls when they could not make face-to-face attendances. There was no risk assessment of the
impact on the Service, and no audit of whether this was sufficient to manage the Service.
There is no contingency plan in place should this issue arise again

Response:
The Children’s Asthma and Allergy Service have learnt many lessons from the practices
undertaken during the pandemic and recognise video consultations could have benefitted
patients at the time and may have helped improve the review assessments and important
patient observations, and the service regrets that AccuRx (video consultation platform) was not
deployed earlier.

Following a successful pilot of the AccuRx, the service has now implemented its use and
blended this into the timetable of review assessments, offering service users an initial face to
face clinic assessment, followed by a review assessment utilising AccuRx. With the option of
an additional telephone review assessment. The app helps improve communication between
the Service and service users. The patient image feature in AccuRx is designed to enable
patients to attach images to provide clinicians with the additional information to inform their
care. The Business Continuity Plan has been updated which now includes the use of video
consultations and alongside new and additional aerosol generating safe venues for face to
face assessments such as the bespoke Clinician at Rochford Hospital and specially identified
clinic spaces in primary care settings risk assessed to be covid secure. The Standard
Operating Procedure (SOP) and Business Continuity Plan now include clarity on when video
consultations should be considered for use:

The service criteria for utilising AccuRx is the following;

• To be used as the preferred contact following the initial assessment.
• Any child/young person where there are concerns regarding inhaler or peak flow

technique

• Any child/young person where there may be safeguarding concerns and face to face

appointments are difficult to obtain.

• Any young person who are in their GCSE years or undertaking exams.
• A home where there is suspected damp/mould.

AccuRx does not replace the importance of seeing the patient in a face to face setting
therefore if there are concerns regarding the patient, utilising face to face clinics/home visits
will be a priority over AccuRx or telephone clinics.

Concern c) The Service relied on telephone contact, Nurses did not speak to William although
he was old enough to be involved in his care

Response:
Current practice is to ensure all nurses request to speak with the child, if they are old enough,
at all consultations - whether this is via telephone or video. During face to face clinic

appointments and home visit consultations, the Child / Young Person (CYP)’s view of their
asthma is recorded within the voice of the child section of the electronic patient record to
ensure all relevant parties including the GP and acute care clinicians are able to view this.

The service model provides pre-booked appointments determined by clinical triage and acuity
of clinical presentation, which affords service users the opportunity and dedicated time to seek
supportive management; however this provision is flexible according to patient clinical need.
Record keeping is undertaken at each consultation to ensure contemporaneous and accurate
documentation, to include potential referral and escalation to secondary care.

The outcome of all clinic consultations are documented within the patient record. Annual record
keeping audits are undertaken monitor the consistency of assessments. This practice is further
monitored during clinical supervisions sessions, caseload reviews and random spot checks.

Lessons learnt

In order to continue to learn lessons from this unfortunate tragic event, the service has
undertaken a review of the existing capacity and demand, to identify the maximum
effectiveness and efficiency of the current resource for the service user. Resulting in a refined
service model with a robust patient journey either returning to primary care once stabilised or
transition onwards to either secondary or tertiary care. As a way in which to manage risk,
asthma care is shared amongst the multidisciplinary team, which includes primary care,
secondary care and tertiary care.

Whilst being mindful of not repeating the evidence provided to your Court during this Inquest,
we respectfully re-iterate the assurances set out in the learning statement submitted during the
inquest and the subsequently developed Action Plan to monitor compliance for the service
which highlighted the following:

a) To ensure evidenced-based education and training for all MSE paediatric staff regarding
medical devices involved in the management of Asthma. This was completed accordingly
with the ward staff at Southend Hospital and then the subsequent employment of the
acute clinical nurse specialist for asthma has continued with this for all acute paediatric
staff.

b) All CYP to receive a written Asthma Action management plan at each children’s

community Asthma & Allergy nurse consultation. The service has adopted and
implemented the BEAT asthma/wheeze action plan.

c) The Children’s Community Asthma and Allergy (CAAS) referral form content has been

reviewed and updated to provide safety netting and prioritisation or exclusion criteria. This
has been completed and revised in accordance with the clinical lead for the integrated
care system.

d) CAAS assessment of CYP medication and inhaler technique – medication storage and

environmental factors. This is assessed at every face-to-face visit and is discussed during
video consultation/ telephone reviews.

e) Upon discharge from the acute provider, an initial contact is actioned within five working
days from hospital discharge, pending a face to face initial assessment scheduled within
two weeks. Allocation of the Rag rating criteria to support patient directed contact

f) All CYP presenting to the ED with a suspected diagnosis of asthma are reviewed by the
CAAS. The service is offered to those who have attended the ED on one occasion.

g) Complex patients with uncontrolled asthma are reviewed by the lead paediatrician and
CAAS at the monthly joint clinic and excellent collaborative relationships established.

h) The outcome of all clinic consultations are documented within the patient record.
Annual recordkeeping audits are undertaken to demonstrate compliance with the
recordkeeping template to ensure equity and consistency of the assessments.

i) Since the pilot integration of the children’s asthma and allergy service into the primary
care networks, all GP practices have been requested to share access of the patient
record , which means the nurses are able to view the prescription history prescribed for
the patient by the GP./practice nurse.

j) The service has developed a protocol which includes the required frequency of contacting
patients, investigations required, symptom management and a robust guide on how to
recognise and escalate patients who have high risk asthma. Patients/families are now
specifically asked how many times they use their inhaler, i.e. it was previously more than
3 times a week – This has now been amended to more than 2 times a week. Additional
questions such as symptoms affecting their sleep and ability to take part in
activities/exercise are also enquired. If the patient has sufficient developmental
understanding, the Asthma Control Test score is implemented

k) Complex uncontrolled asthma patients who have progressed through the Amber caseload
with minimal improvement are discussed at peer clinical supervision sessions and difficult
asthma meetings as appropriate. Caseload reviews are undertaken with the team at three
monthly intervals with the RAG rating allocated, in order to apply the relevant safety
netting for the service user.

l) All service providers to ascertain if parents/carers are able to read written care advice or
directions provided. Documented within the patient record and a number of translated
care plans are available to families

m) Databases are compiled / reviewed of all service users who have been offered

appointments and declined the service offer

n) All CAAS staff to undertake the online smoking cessation course, completed for existing
staff members and will be provided to new starters in the event of staff recruitment.

o) All staff receive notification of updated nice guidance, this is circulated for information and

the service is measured against the baseline assessment tool provided by NICE.

p) All new starters on induction to the services receive the relevant SOPs/ policies

q) To continue to develop links between universal services and the CAAS to improve

education and training, to promote safe management, by addressing potential symptom
management concerns/issues. Attendance at the universal services education forums is
timetabled on a rolling programme and a database collated.

I hope that I have provided reassurances around the steps that we have taken to address the
issues of concern contained within your report. We know there is an acute need to embed and
effect change, hence we will monitor the above provisions to ensure these are contributing to
our overall aim of keeping patents safe and delivering therapeutic care.

Please do let me know if you require any further information at this stage, including copies of
any of the documents referred to above.

We will await your direction before sharing a copy of this reply with the family.

Yours sincerely

Executive Chief Operating Officer / Deputy CEO

Response from Essex Partnership University NHS Foundation Trust (PDF)