Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0220, written 9 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2025 |
|---|---|
| Reference | 2025-0220 |
| Deceased | Jake Lawler |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Child Death (from 2015) |
| Organisation named | Manchester University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care CORONER lam Alison Mutch , senior coroner, for the coroner area of Manchester South CORONER’S LEGAL POWERS | 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 8° November 2024 | commenced an investigation into the death of Jake Samuel Lawler. The investigation concluded at the end of the inquest on 15" April 2025. The conclusion of the inquest was narrative: Died from a biventricular arrhythmogenic cardiomyopathy when he was incorrectly diagnosed in life with exercise induced asthma and the significance of a witnessed exercise induced syncope episode, and an abnormal ECG were not recognised or actioned appropriately. The medical cause of death was 1a) Biventricular arrhythmogenic cardiomyopathy 4 | CIRCUMSTANCES OF THE DEATH Jake Samuel Lawler was diagnosed by his GP practice with exercise induced asthma and prescribed treatments that did not have any significant impact on his symptoms. On 13th October 2024 Jake collapsed while playing football and had a short period of unconsciousness. He was taken to Wythenshawe Hospital by his father. A full history was given that was consistent with an exercise induced syncope. An ECG was carried out. That was abnormal and showed a T wave inversion on lead V5. The clinicians noted there was the T wave inversion but did not recognise that this was a concerning finding from the ECG. The history given by his father was not assessed correctly. The T wave inversion particularly in combination with his collapse should have resulted in him being referred for an inpatient paediatric review and further testing. It is probable that he would not have died on the day he did had the correct actions been taken. Jake's collapse was incorrectly attributed to his exercise induced asthma. He was referred back to the GP for review. He was reviewed by a GP by telephone on 14th October and face to face on 18th October 2024. A FeNO test referral to the asthma nurse was made. On 31st October 2024 the FeNO test was conducted. The asthma nurse referred Jake back to the doctor indicating they did not believe Jake had asthma. There was a plan to refer him to paediatrics. It was clear that the diagnosis of exercise induced asthma being the cause of his collapse on the 13th October 2024 was unlikely and that the working diagnosis within the discharge summary was probably incorrect. The significance of that was impacted by the discharge summary incorrectly describing the ECG as normal. On 5th November 2024 whilst playing football Jake collapsed. Attempts to resuscitate him were unsuccessful and he died at Wythenshawe Hospital on 5th November 2024. The postmortem carried out found he had died as a consequence of having Biventricular arrhythmogenic cardiomyopathy 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 1. The inquest heard evidence that the significance of 12 lead ECG readings are regularly missed or misunderstood by clinicians which means that key warning signs are missed as in Jake’s case. It is unclear if this is a training issue or the way in which the machines report or volume. Without an improvement there will be further avoidable deaths 2. Jake presented with a clear paediatric exercise induced syncope. The inquest was told that there is no clear national guidance on the pathway to be followed in relation to such children although medical training emphasised that this should be treated asa red flag event. 3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms. This was compounded by the exercise induced syncope being incorrectly linked to asthma. In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma. In Jake’s case the readings and answers pointed to a well-controlled asthma. This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern. This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture. A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy 4. ECGs to rule out a possible cardiac issue cannot easily be given to children in a community setting. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths, and | believe you and/or 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 4th July 2025. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mother and Father of Master Lawler on behalf of the family, Manchester University NHS Foundation Trust, GP Surgery who may find it useful or of interest. | 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. They may send a copy of this report to any person who they believe 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. Alison Mutch HM Senior Coroner 09/05/2025
1 response 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.
Minister of State for Health and Secondary Care 39 Victoria Street London SW1H 0EU Our ref: HM Coroner Alison Mutch Coroner’s Court, 1 Mount Tabor Street, Stockport SK1 3AG By email: manchestersouthcoroners@stockport.gov.uk 18 August 2025 Dear Ms Mutch, Thank you for the Regulation 28 report of 9th May 2025 sent to the Secretary of State for Health and Social Care about the death of Master Jake Samuel Lawler. I am replying as the Minister with responsibility for Secondary Care. Firstly, I would like to say how saddened I was to read of the circumstances of Master Lawler’s death, and I offer my sincere condolences to his 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. The report raises concerns over 12 lead electrocardiogram (ECG) readings being frequently misunderstood; a lack of clear national guidance for paediatric exercise induced syncope; difficulties with the national asthma scoring system at facilitating scoring for exercise induced asthma and therefore potentially masking differential diagnoses; and difficulty giving ECGs to children and young people in community care settings. In preparing this response, my officials have made enquiries with NHS England (NHSE) to ensure we adequately address your concerns. I note your concerns about training and national guidance. Individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice. We would expect NHS Trusts and other relevant organisations to ensure that their protocols are appropriate in the wake of the death of Master Lawler. I note that Manchester University NHS Foundation Trust has considered how to improve both training and guidance as part of their Safety Improvement Plan, which they have shared with NHSE. NHSE have noted and welcomed the actions for improvement being undertaken by the Trust in response to this matter, as do we as a Department. These include, but are not limited to: • Ensuring that the North West Congenital Heart Disease Operational Delivery Network’s (NWCHDN’s) Paediatric Cardiology Outpatient Referral Guidelines are shared with all Clinical Group Emergency Departments (EDs); • A review of the referral guidelines to consider the development of an addendum specific to the Trust’s EDs, with a clear pathway for referral to paediatric cardiology; • Development of a Paediatric ECG E-learning with a focus on risk stratification and the assessment and management of syncope; • Development of teaching slides to include all cardiac causes of exertional syncope; • Consideration of how the Trust’s Electronic Patient Record system (HIVE) can alert staff to red flag signs and symptoms, with a list of abnormal paediatric ECGs that could indicate a more serious cardiac condition; • Development of a new Standard Operating Procedure for the review of adult and paediatric ECGs across the Trust; • Consideration of a new Patient Safety Priority to support reduction in the number of abnormal ECGs. When my officials discussed the matter with NHSE they agreed that the misinterpretation of ECG findings is unfortunately not uncommon, and this is especially true in children. Children should therefore have ECG interpretations carried out by an expert clinician who has been trained in interpretation in the young, preferably from a congenital heart disease background. NHSE colleagues also confirmed that they view certain skills as key parts of medical practice. This includes recognising the importance of exertional syncope and what the required next steps are, and the differential diagnoses for breathlessness. Further information can be found at the following links Causes | Background information | Blackouts and syncope | CKS | NICE; Recommendations | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE. Regarding your concerns about a lack of professional curiosity and a holistic view of Master Lawler’s care, NHSE has been engaging with the family of Jess Brady who have been campaigning on similar issues. Jess Brady died at the age of 27 of cancer on 20th December 2020. In the five months leading up to her death she contacted her GP multiple times without her cancer being diagnosed. In her memory, Jess’s family established The Jessica Brady CEDAR Trust, which is campaigning for Jess’s Rule: “three strikes and rethink”, a proposal that would encourage GPs to rethink a diagnosis when a patient returns three times with the same symptoms or concerns. Government officials are engaged with the Brady family. As part of efforts to highlight the issues raised by Jess’s care, NHSE are featuring her case in the 2024 NHSE Primary Care Patient Safety Strategy to raise awareness of the need to ‘rethink’ when symptoms remain persistent or unexplained after multiple presentations. The strategy is a clinically led approach for primary care professionals to improve patient safety in general practice. I also noted your comment on the difficulties obtaining ECGs for children and young people in the community. NHSE is looking to improve paediatric expertise in the community by supporting local systems to implement neighbourhood multidisciplinary teams for children and young people. These will allow hospital paediatricians to work closely with primary care and improve access to this needed expertise in the community. Guidance was published to support systems in February 2025 and can be read at NHS England » Guidance on neighbourhood multidisciplinary teams for children and young people I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, Minister of State for Health and Secondary Care
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