Tamara Mills

The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care ofher family_ There was i) No co-ordinating record of these occasions No analysis of the frequency Or circumstances of the events No analysis of the medication level of medication prescribed No determination of its effectiveness the frequency O regularity of its use No appreciation of the deteriorating nature of her respiratory condition Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care Overall In the absence ofno one individual assuming responsibility for her care, there was no plan directed towards her long term management care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment; control and resolution of the recurring episodes. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event; but not as a part of the necessary strategy to control and avoid such events. Not only did those advised of such & plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term_ In and of itself this episode demonstrates a profound and woeful indication of the lack of understanding ofhow this condition; its recurring nature can and should be managed by someone with the proper training and understanding of this chronic respiratory disease_ Two further areas of concern presented, inter related but independently significant and critical in this matter A) Tamara' $ mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment B) Evidence was also received of the development ofa Tertiary service designed to improve medical care in the area of paediatrics. There was a singular lack of 'understanding by practitioners ofhow referrals to the service Were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust_ The net result of this inhibition a further fragmentation in the care and management of the patient: ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did deronstrate their ability to make a difference if had been permitted in one instance to assume long term management of the child'$ care and iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation Tamara was never formally referred to this level of service_
10. The National Review of Asthma Death (NRAD) 20//-2014 was published in a report entitled Why Asthma still Kills 0n the 6"h 2014 month after Tamara'$ death: The Review' $ evidence based conclusions and recommendations exemplify and underline the same missed opportunities and poor practice which lead to Tamara'$ death.
11. The conclusions of the Review would not of themselves have impacted on the events leading to Tamara' $ death but in the context of seeking to avoid future deaths, the Review and the evidence of Tamara $ Inquest identify a need by both national and local agencies to revisit the recommendations of the Review, the formal substance of training identified as appropriate for the care and treatment of Asthma, the nature of that disease and the strategies essential for the term management, care and prevention of uncontrolled re-occurring altacks 12, it is right to acknowledge that the local Trusts in this matter have responded to the criticism directed towards them and sought to identify better practices for the future, their experience needs to be shared by and with other medical care professionals 0n1 a continuing basis and their resolve to do so evidence of their commitment the lessons that apparently have been learnt. and they May [ong -

13. There are undoubtedly resource issues implicated in this matter but a demonstration of resolve and an effective lead given by the Department of Health those involved in the provision of Health Service guidance and education nationally would demonstrate a universal resolve to standardise the care of chronic asthma patients and to make paediatric asthma death never event"_ Action _Should bc_Takew In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action Your Response You are under a to respond to this report within 56 of the date of this report, namely by December 2015. [, the Coroner; may extend the period. Your response must contain details of action taken O proposed to be taken, setting out the timetable for action. Otherwise YOu must explain why no action is proposed. Copies & Publication have sent a copy of my report to the Chief Coroner and to the following Interested Persons and her Solicitor Browell Smith Co {and to the Local Safe-Guarding board (where the deceased was under 18)} . have also sent it to the Healthcare Quality Improvement Partnership, Royal College of Physicians, 1 St: Andrews Place, Regents Park; London NWI 4LE who may find it useful or of interest. am also under a duty t0 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 Date: 29mh October 2015 {Signature} Senior Coroner Gateshead & South Tyneside and 24"h days duty