NHS trust and GP surgery slammed over 'woeful' care of schoolgirl who died of an asthma attack
PUBLISHED: 07:00 04 June 2019
An NHS trust and doctor's surgery have been slammed for missing opportunities to help a 10-year-old schoolgirl who died of a severe asthma attack even though she had seen medics 48 times before.
Sophie Holman went with her mother with breathing difficulties to the Ripple Road Medical Centre in Barking on December 12, 2017.
She was sent home with a steroid prescription and told to take a high dose of quick relief medication. But the next day she and her parents left for hospital with her condition not improving.
However, Sophie collapsed after getting short of breath on the way and in spite of attempts to resuscitate her by bystanders, paramedics and hospital staff, she died that day.
In a damning report since her tragic death, Eastern Area of Greater London assistant coroner, Dr Shirley Radcliffe, criticised Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) and the surgery.
Dr Radcliffe lists a string of failures and missed opportunities which could have prevented Sophie's death.
Sophie was admitted to BHRUT - which operates Queen's and King George hospitals - on four occasions and had also been treated in A&E for acute asthma 18 times.
A total of 70 per cent of her visits were later recorded as being severe or life-threatening but each time her attacks were treated as isolated events.
A child protection system counting the number of A&E visits made by children ignored asthma meaning medics were not alerted to the frequency of Sophie's visits.
Dr Radcliffe found one BHRUT paediatrician did not have enough experience to spot the risks to Sophie and that in spite of having 12 doctors specialising in children none had an interest in respiratory diseases.
"Overall the department failed to view Sophie's asthma as a potentially life-threatening or long term condition requiring a long term plan," the report says.
The family was also not told how severe Sophie's condition was, which the assistant coroner said could explain why the youngster missed seven out of 10 outpatients appointments.
Sophie is the fourth asthma death in childhood in the north east London NHS area since 2016.
Dr Radcliffe found 'there were many missed opportunities' to address underlying problems when it came to Sophie's medical care during 48 hospital and surgery visits over 10 years.
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And despite 'numerous' health professionals getting involved, no indiviual or organisation took responsibility for managing her overall care, the report says.
Management of Sophie's asthma also demonstrated examples of poor practice raised in a national review of asthma deaths published three and a half years before her death.
Records at BHRUT and the surgery were also unclear about the possibility Sophie could die from an asthma attack.
"[T]his episode demonstrates a profound and woeful indication of the lack of understanding of how this condition should be managed", the report says.
Dr Radcliffe called on the Department of Health and Social Care (DHSC) to standardise care to stop another child asthma death.
Dr Magda Smith, chief medical officer at BHRUT, said: "It's clear that Sophie was failed by the system and we are very sorry for the part we played.
"We collectively failed to identify a significant underlying health issue; to investigate or escalate appropriately and to communicate effectively with each other as medical professionals or with Sophie's parents.
"We've been working with GPs to ensure this doesn't happen again by improving training and introducing more clinics as well as a dedicated nurse specialist who'll support children and families.
"We hope this and other recent tragic cases elsewhere in the country will help ensure this issue is given appropriate weight at national level to drive change and prevent future child asthma deaths."
A spokesman for Ripple Road Medical Centre said: "The practice would like again to extend sincere condolences to the family and friends.
"Following this sad event, we re-evaluated the processes in place in relation to the management of asthma at the practice.
"This included an audit of care provided and a review of practice asthma protocols, guidelines and training, and has resulted in a comprehensive new asthma action plan.
"We continues to strive to provide the best possible care to all of our patients."
A DHSC spokesman said: "As part of our long term plan, we want the NHS to be the safest healthcare system in the world.
"This will include the development of new models of integrated care for children and young people with asthma to share best practice and integrate paediatric skills across services."