Asthma is one of the most common medical conditions, with an estimated five and a half million people in the UK having this condition, i.e. 1 in 10 people.
The startling statistic is that every 10 seconds there is a person having a potentially lethal asthma ‘attack.’
The latest data shows that over 1,200 children and adults died in 2014, with an economic cost of £1 billion to the NHS (with a much greater economic impact to society as a whole, from loss of earnings and impact on productivity).
Some cases start in childhood and although a number of children grow out of it, it is the most common long term medical problem in the UK.
Some of these deaths are certainly preventable. There have been investigations into reducing the number of deaths, but ‘Why asthma still kills’, from the Royal College of Physicians, is the first national audit of asthma deaths in the UK and has a series of recommendations to reduce the number of deaths caused by asthma.
The report divides into 4 distinct sets of recommendations, namely:
- the organisation of NHS service;
- medical and professional care;
- prescribing and medicine use; and finally
- patient factors and perception of risk.
These are given in full below, including the recommendations regarding patient factors and risk, as there may be mitigating circumstances in an asthma death.
Organisation of NHS services
- Every NHS hospital and GP surgery should have a designated, named clinician for asthma services, responsible for formal training in the management of acute asthma.
- Patients with asthma must be referred to a specialist asthma service if they have been given more than two courses of systemic corticosteroids (oral or injected) in the previous 12 months or require management using British Thoracic Society (BTS) stepwise treatment 4 or 5 to achieve control.
- Follow-up arrangements must be made after every attendance at an emergency department or out-of-hours service for an asthma attack. Secondary care follow-up should be arranged after every hospital admission for asthma, and for patients who have attended the emergency department two or more times with an asthma attack in the previous 12 months.
- A standard national asthma template should be developed to facilitate a structured, thorough asthma review. This should improve the documentation of reviews in medical records and form the basis of local audit of asthma care.
- Electronic surveillance of prescribing in primary care should be introduced as a matter of urgency to alert clinicians to patients being prescribed excessive quantities of short-acting reliever inhalers, or too few preventer inhalers.
- A national ongoing audit of asthma should be established, which would help clinicians, commissioners and patient organisations to work together to improve asthma care.
Medical and professional care
- All people with asthma should be provided with written guidance in the form of a personal asthma action plan (PAAP) that details their own triggers and current treatment, and specifies how to prevent relapse and when and how to seek help in an emergency.
- People with asthma should have a structured review by a healthcare professional with specialist training in asthma, at least annually. People at high risk of severe asthma attacks should be monitored more closely, ensuring that their PAAPs are reviewed and updated at each review.
- Patients must be routinely asked what factors trigger or exacerbate their asthma, and these must be documented in the medical records and PAAPs, so that measures can be taken to reduce their impact.
- An assessment of recent asthma control should be undertaken at every asthma review. Where loss of control is identified, immediate action is required, including escalation of responsibility, treatment change and arrangements for follow-up.
- Health professionals must be aware of the features that increase the risk of asthma attacks and death, including the significance of psychological and mental health issues.
Prescribing and medicines use
- All asthma patients who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required.
- An assessment of inhaler technique to ensure effectiveness should be routinely undertaken and formally documented at annual review, and also checked by the pharmacist when a new device is dispensed.
- Patients should be continually monitored to ensure that they continue to use their ‘preventer inhalers’.
- The use of combination inhalers should be encouraged. Where long-acting beta agonist (LABA) bronchodilators are prescribed for people with asthma, they should be prescribed with an inhaled corticosteroid in a single combination inhaler.
Patient factors and perception of risk
- Patient self-management should be encouraged to reflect their known triggers, such as increasing medication before the start of the hay fever season, and avoiding non-steroidal anti-inflammatory drugs (such as Ibuprofen).
- Any history of smoking and/or exposure to second-hand smoke should be documented in the medical records of all people with asthma. Current smokers should be offered help to quit.
- Parents, children and teachers should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, recognising when asthma is not controlled, and knowing when and how to seek emergency advice.
- Efforts to minimise exposure to allergens and second-hand smoke should be emphasised, especially in young people with asthma.
These standards are helpful in the context of reducing the mortality and morbidity from asthma, as well as helping to reduce the prevalence (amongst children) from being the highest in the world.
In reviewing a death due to asthma, it is important to see if there were steps that could have been taken to prevent the fatality.
The management regimes given above are known to healthcare providers and should be applied in the delivery of care to asthmatic patients. The following have all been described:
- failure to establish a system of care;
- failure to review and establish an asthma management plan;
- the inability of a patient to adhere to a medication regime or the prescription of an incorrect regime;
- patients making themselves at greater risk of an asthma episode.
The medical and organisational aspects of the care not being adequately delivered may be the basis of a successful claim.
If you would like further information about this particular topic, or wish to discuss the possibility of bringing a claim for Clinical Negligence - or indeed any other type of injury, please contact the Dutton Gregory Clinical Negligence Team on (01202) 315005, or email firstname.lastname@example.org
NB This article does not constitute legal advice and should not be relied on as such. No responsibility for the accuracy and/or correctness of the information and commentary set out in the article, or for any consequences of relying on it, is assumed or accepted by any member of Dutton Gregory LLP.