A CORONER has concluded "multiple failures" and "neglect" contributed to the death of a ten-year-old Southend boy who suffered a fatal asthma attack. 

An inquest into the death of William Gray, 10, was concluded in Essex Coroner’s Court, Chelmsford, today.

Area Coroner Sonia Hayes concluded the natural cause of death was 1a cardiac arrest secondary to respiratory arrest due to 1b acute asthma secondary to chronic very under controlled asthma.

She stated his asthma should have been escalated and treated further which "should have saved William's life". 

William suffered an initial serious asthma attack in October 2020 and the coroner insisted this should have highlighted how serious his condition was and led to further and improved treatment. 

Ms Hayes added:  “William Gray died as a consequence of failures by healthcare professionals to recognise the severity and frequency of his asthma symptomatology and the consequential risk to his life that was obvious.

“William’s death was contributed to by neglect. William’s death was avoidable. There were multiple failures to escalate and treat William’s very poorly controlled asthma by healthcare professionals that would and should have saved William’s life.”

Prior to October 2020, William’s asthma was generally ‘well controlled’ and he had not been admitted to hospital for any asthma attacks in the previous three years.

William had an initial life-threatening asthma attack on October 27, 2020 which required his mother, to perform CPR and a visit from paramedics who took him to hospital.

During this asthma attack, William was prescribed adrenaline which Dr Parthasaradhi Rachakonda, former clinical at Southend Hospital, said he hadn’t seen in ‘more than 20 years of experience’ .

He was discharged a few hours later which his mother found ‘strange’ as William’s previous and less severe attacks required him to stay in hospital overnight.

Ms Hayes added: “William should not have been discharged after four hours and this was a key factor in the ongoing underestimation of the severity of that attack by healthcare professionals."

A lack of communication and organisation between health professionals meant William’s check ups were sporadic.

Appointments were during covid time and were ‘five minutes at most’ on the telephone.

William also had a four-month period between February and May 2021 where he had no appointments.

His next asthma attack on May 29, 2021 saw paramedics struggle to clear his airways.

Coroner Hayes noted he first of two calls by his mother to 999 should have been a "category 1". She also said William should have received adrenaline sooner in the evening, as he was only given it when in the ambulance. Coroner Hayes said there was a "significant delay" in the adrenaline being given after he went into cardiac arrest.

She added health professionals did not William’s monitoring between October 2020 and May 2021 did not meet guidelines set by the British Thoracic Society.

The Mid and South Essex NHS Trust, Essex University Partnership Trust and the East of England Ambulance Service Trust have been approached for comment.