Source · Prevention of Future Deaths

Kalila Griffiths

Ref: 2020-0299 Date: 18 Dec 2020 Coroner: Nadia Persaud Area: East London Responses identified: 1 / 1 View PDF

Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.

Date 18 Dec 2020

56-day deadline 17 Feb 2021

Responses identified 1 of 1

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths

Coroner's concerns

AI summary

Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.

View full coroner's concerns

(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented. The recommendations of importance in this case were:

 Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.  Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.  Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.  Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.

(2) Clinicians raised concerns in relation to the number of different guidelines relating to asthma (NICE Guidelines, BTS/SIGN Guidelines and GINA Guidelines). It was noted that there are discrepancies between the guidelines. This makes it difficult for those general practitioners and emergency care practitioners who are providing care to patients.

(3) It was noted that it is not clear to healthcare professionals which guidelines should be used for the management of acute asthma attacks. Many clinicians consider that the NICE guidelines can be used for the management of an acute asthma flare-up. The Inquest heard that this is incorrect and that the BTS/SIGN guidelines should be used.

(4) The evidence revealed that further training is required for GPs and emergency departments in providing safe asthma care.

Responses

1 respondent

NHS England NHS / Health Body

18 Dec 2020 PDF

Action Planned

NHS England published the NHS Long Term Plan which has a clear commitment to improve the outcomes for those with a respiratory condition including asthma. NHS England and NHS Improvement commission the National Asthma Audit Programme that provides data on a range of indicators to show improvements and opportunities in asthma outcomes. (AI summary)

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Dear Ms Nadia Persaud Thank you for your Regulation 28 report, dated 18th December 2020, concerning the tragic death of Kalila Elizabeth Griffiths on 1st February 2019. I would like to express my deep condolences to Kalila’s family. You have raised concerns regarding the care and follow-up leading to Kalila’s death and the general management of asthma patients in the NHS. NHS England published the NHS Long Term Plan1 in January 2019. The plan has a clear commitment to improve the outcomes for those with a respiratory condition including asthma. Since the publication of the Long Term Plan there is now a National Respiratory Programme working across a number of priority areas including the improvement of asthma outcomes. There have been significant improvements in asthma care since the publication of the National Review of Asthma Deaths in 2014. Asthma deaths in younger people are falling, with under 65 year old deaths reducing by half in the last 15 years2. As your report mentions there is still further improvements to be made. NHS England and NHS Improvement commission the National Asthma Audit Programme that provides data on a range of indicators to show improvements and opportunities in asthma outcomes. In response to your recommendations of the case I have outlined the work currently in progress that is contributing to the improved outcomes for people with asthma. Where people with asthma require specialist input this may include seeing a nurse or other healthcare professional with the competency and training to assess, treat and manage asthma. This combined with monitoring of asthma exacerbations (within QOF) is the first

1 https://www.longtermplan.nhs.uk/ 2https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/005955asthmadeathsinenglandandw ales2001to2015occurrences

National Clinical Director for Respiratory Disease Clinical Policy Unit Medical Directorate

16th February 2021

step in ensuring that correct treatments and other interventions are administered in a timely manner. The British Thoracic Society (BTS) asthma discharge bundle3 describes five high impact actions to ensure the best clinical outcome for patients attending hospital with an acute asthma attack. The aim is to reduce the number of patients who are readmitted following discharge and to ensure that all aspects of the patient’s asthma care are considered. The bundle includes: checking of medicines, inhaler technique, action plan, triggers for exacerbations and follow-up in the community within two working days and specialist care according to criteria within two weeks. This is nationally recommended as best practice following hospital admission for an asthma attack. An update to the GP contract4 for (to be implemented in 2021) includes an improved Quality Outcomes Framework (QOF) asthma domain: The content of the asthma review has been amended to incorporate aspects of care positively associated with better patient outcomes and self-management, including a review of inhaler technique, a record of the number of exacerbations in the previous 12 months, provision of a personalised asthma action plan and a validated measurement of asthma control to assess how the patient is managing their condition. The asthma review is a key component in reducing the risk of asthma attacks and the need for acute admissions. The QOF for 2020/21 has been revised in response to COVID-19 to release capacity within general practice to focus efforts upon the identification and prioritisation of people at risk of poor health and those who experience health inequalities for proactive review including:
• Those most vulnerable to harm from COVID-19; evidence suggests that this includes patients from black and ethnic minority groups and those from the 20% most deprived neighbourhoods nationally.
• Those at risk of harm from poorly controlled long-term condition parameters (including asthma); and,
• Those with a history of missing annual reviews Data systems are already in place, further work is needed to ensure the data is analysed and used to inform patient treatment plans. There is also the wider issue of medicines adherence, which is again part of the work of the Long Term Plan. The Long Term Plan presents opportunities to ensure medicines optimisation and prescribing are integrated within the asthma care plan and annual reviews. The British Thoracic Society/SIGN and NICE are working collaboratively to produce a single guideline on the diagnosis and management of asthma. A single guideline will ensure there is no confusion for healthcare professionals. The ambition is to start production of the new guideline in 2021.

3 https://www.brit-thoracic.org.uk/media/70102/bts-asthma-care-bundle-april-2016-v3.pdf 4 https://www.england.nhs.uk/wp-content/uploads/2020/03/update-to-the-gp-contract-agreement-v2-updated.pdf

There are well established clinical guidelines for healthcare providers to follow, this includes both national and international guidelines:
• BTS/SIGN management of asthma5
• NICE guideline on asthma diagnosis monitoring and management6
• Global Initiative for Asthma7

I would like to thank you for raising these important patient safety concerns, we will endeavour to do more to improve the outcomes for people with asthma to prevent such a tragedy in the future. Please do not hesitate to contact me should you need any further information.

Report sections

Investigation and inquest

On 5th September 2019 I commenced an investigation into the death of Kalila Elizabeth Griffiths, age 22. The investigation concluded at the end of the inquest on the 14th December 2020. The conclusion of the inquest was a narrative conclusion: Kalila Griffiths died from natural causes. Her death was however contributed to by a lack of recognition of the seriousness of the decline of her respiratory state in the 4 weeks leading up to her death. By the 19th January 2019 Kalila required a review by a respiratory physician. Had such a review taken place, on the balance of probabilities, her death would have been avoided.

Circumstances of the death

Kalila Griffiths had complex medical history including, asthma, Ehlers-Danlos syndrome and postural tachycardia syndrome. In December 2018 she developed shortness of breath. She attended her GP surgery on the 4th January 2019. The GP prescribed medication for a chest infection and for asthma. Despite this treatment, Kalila’s respiratory health deteriorated during January 2019 rendering her largely unable to mobilise. She was confined to her bedroom for most of January 2019. Kalila required at least four attendances at her GP practice and two attendances to A & E (6 and 19 January). The second A&E attendance - 19th January 2019 - followed a life-threatening deterioration in her breathing. Kalila had recorded an oxygen saturation of 74% prior to presentation at the hospital. She had been unable to speak to the 111 operator and she could be heard with a continuous cough in the background. Notwithstanding her poor clinical state, she was discharged from hospital without the required observation; clinical assessment and history gathering. She required admission to hospital at this time, for assessment by a respiratory physician. Had she received observation in hospital and assessment by a respiratory physician on the 19th January 2019, on the balance of probabilities her death would have been avoided. Kalila passed away on the 1 February 2019. The direct cause of death was a pulmonary embolism. Her asthma was found to have contributed to her death.

Her medical management on the multiple presentations over a short space of time, appears to have centred largely on treating the immediate presentation as an isolated event. Insufficient account was given to the risk of ongoing attacks and other complications arising.

The Inquest heard that the general practice and the Trust involved in this case have taken a number of steps to improve the care provided to asthma patients. The Inquest however heard from a number of witnesses that there are concerns about the care provided to asthma patients nationally.

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Report details

Reference: 2020-0299
Date of report: 18 December 2020
Coroner: Nadia Persaud
Coroner area: East London

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Feb 2021.

Sent to

NHS England

Source links

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Data: judiciary.uk under OGL.