“Mid & South Essex NHS Foundation Trust (1) Experienced hospital paediatric doctors all…”

The coroner’s concerns

– 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 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 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. 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 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 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 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. 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

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0511

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0