A CORONER has raised serious concerns with the Secretary of State for Health around the prevention and treatment of asthma attacks following the tragic death of 10-year-old William Gray.

Following an inquest into the death of the Southend boy, Sonia Hayes, area coroner for Essex, concluded there had been "multiple failings" by health professionals to recognise and adequately treat his asthma causing his death. She added that "neglect" by healthcare professionals contributed to William’s death.

William had suffered a near-fatal asthma attack on October 27, 2020 which he survived. He died seven months later, on May 29, 2021, after going into cardiac arrest caused by a respiratory arrest resulting from his asthma.

Now, the coroner has written a "prevention of future deaths report" identifying matters of concern. 

In her report, the coroner told the Secretary of State for Health that she is concerned that training for health professionals who care for children and young people with asthma is not mandatory.

She also raised concerns with the Association of Ambulance Chief Executives that the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) national paramedic guidelines are not clear about how to properly manage life threatening asthma in children - which is a rare event for paramedics - and said these should be clarified. 

The report also expressed concerns that the East of England NHS Ambulance Trust’s investigation into William’s death did not scrutinise the previous ambulance attendance and "missed several opportunities" to understand the issues with the attendance on the night of his death.

Concerns were raised that experienced hospital paediatric doctors at Mid and South Essex NHS Foundation Trust were unaware that giving intramuscular adrenaline was part of the JRCALC guidelines for life-threatening asthma.

The report outlined a number of issues at Essex University Partnerships NHS Foundation Trust’s asthma and allergy children’s and young persons’ service.

This included nurses not speaking to William despite him being old enough to be involved in his care, the service remaining "under resourced", and video calls not being introduced in the pandemic when they could not offer face to face appointments 

She says there was, and is still, "no contingency plan in place should this issue arise again".

All five organisations are under a duty to respond to the coroners concerns within 56 days of receiving their report. In their responses, they are required to set out the action taken, or proposed action, including a timetable or to explain why no action is to be taken.


In response to the report, William’s mum, Christine Hui, said: “I’m hopeful that the bodies that received William’s prevention of future deaths report take notice and make real change. Trying to adjust to life without him has been horrendous.

“William’s death was a preventable tragedy. I just don't want any other family to go through what we've been through.”

William’s family are represented by solicitor Julie Struthers, at law firm Leigh Day.

She said: “This wide-ranging report from the coroner reflects the extent and seriousness of the evidence heard at William’s inquest about care for children with asthma.

“I hope that the recipients of the report properly consider the coroner’s concerns so that effective improvements are made to prevent such a tragedy from ever happening again.”