An 11-year-old boy would probably still be alive if an ambulance crew had taken him to hospital shortly after he suffered a severe asthma attack, an inquest heard.
A crew attended the home of George Smith in Stickney, Lincolnshire, in October 2017 after an attack – but despite assessment, it was decided he did not need to go to hospital.
Hours later, after they returned and decided to take him, he was dead.
Now George's devastated family have spoken of their heartache – and the East Midlands Ambulance Trust has accepted that he would probably have lived if he had been taken to hospital.
The family are suing the trust for medical negligence for the treatment of their son, reports Lincolnshire Live.
A statement read out by George’s mother Melanie Townend said the family, including his father Robert and his four sisters Chloe, Harriet, Darcey and Beatrix, had spent the day together before he had asthma attacks later on.
Part of the statement read: “It was a severe form of asthma and was something he learnt to live with. An asthma attack could occur suddenly and without warning.
“I can’t even describe how it feels to lose a child. My life is consumed with grief.
“His death has caused unimaginable pain that at the moment I can’t see past. His biggest fear was dying as a result of his asthma.
“Our life as a family will never be the same again.”
George had suffered with brittle asthma for most of his life and needed to make frequent trips to hospital.
He was first diagnosed with breathing problems when he was just nine months old and was diagnosed with brittle asthma at the age of four.
An inquest heard in Boston on Wednesday, that an ambulance was called by his mum at around 11pm on October 22 as George was suffering from a severe asthma attack.
Advice Ms Townend had received from a doctor recommended that she should do this – and it had been regular practice for quite some time.
When the ambulance crew arrived, George was on the landing and had his nebuliser on, which he had at home, and was struggling to breathe.
The crew were there for around 45 minutes, before the decision was taken that he did not need to go to hospital.
A statement from Martin Whittaker, an emergency medical technician, heard that he had conducted a peak flow assessment to assess how air was flowing out of his lungs.
Part of the statement read: “The result from the first test was 100 and the second gave a reading of 80.
“It was indicated that the peak flow was leaving him extremely short of breath so the decision was taken not to do a third one.”
However, what was not noted was that George’s usual reading would be 250, which should have indicated that the attack was serious and he should have been taken to hospital.
George was not taken to hospital as it was observed by the ambulance crew that he had improved because he could stand unaided and speak in full sentences.
However, his mother called a second ambulance at 3.40am on October 23 as he was suffering another attack and had collapsed to the floor.
George had gone into cardiac arrest and his father started CPR. When ambulance crews arrived he was taken to Boston Pilgrim Hospital.
But numerous attempts to resuscitate him failed.
Now the trust says lessons have been learnt.
Evidence from Ian Marsell, head of clinical development at EMAS, heard that the trust had acted upon a number of failings found after the incident.
An investigation was launched within the trust and a serious incident report written, the hearing was told.
The report found that insufficient medical history was taken to help make the decision on how serious the condition was.
There was also a failure of reporting readings and no second phase of peak flow was recorded, which could have indicated any deterioration.
It also found that standard advice is that a child should be taken to hospital at that age.
A letter read out at the inquest from EMAS said: “Tragically we have identified that there was a failure to adequately follow the paediatric care policy.
“This meant that George was not fully assessed in accordance with the trust policy and taken to hospital during the early hours of October 23, 2017.
“The trust deeply regrets this failure. Had George been admitted following the first ambulance, whilst he would have been extremely unwell, he would have likely have survived.”
Following the report, the failings have been addressed with modules on brittle asthma being taught face to face and in online lessons, the trust says.
There are also bulletins and newsletters which regularly go out, according to EMAS.
Coroner Paul Smith gave a narrative conclusion that read: “George Robert Smith was known to suffer from brittle asthma.
“He suffered a severe asthma attack at his home address at around 11pm on October 22.
“An ambulance was called.
"He was not thoroughly assessed in accordance with policy and he was not taken to hospital as he should have been.
“There was no handover to a clinician and he was left in the care of his parents.
“He suffered a further severe asthma attack and another ambulance was called. He was taken to Boston Pilgrim Hospital at 4.35am.
“Attempts to revive him stopped at 4.55am. On the balance of probabilities he would have survived if he was taken in the first ambulance.”
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