Coroner says that tragic asthma death was probably avoidable


On 5th September 2019 Miss N Persaud, a senior coroner in East London commenced an investigation into the death of Kalila Elizabeth Griffiths, age 22.


Kalila sadly passed away on the 1st of February 2019. The direct cause of death was a pulmonary embolism. Her asthma was found to have contributed to her death.


The investigation concluded at the end of the inquest on the 14th of December 2020. The conclusion of the inquest was that Kalila died from natural causes. Her death was however contributed to by a lack of recognition of the seriousness of the decline of her respiratory state in the four weeks leading up to her death. By the 19th January, 2019 Kalila required a review by a respiratory physician. Had such a review taken place, on the balance of probabilities, her death would have been avoided.


The coroner said that her medical management on the multiple presentations over a short space of time appears to have centred largely on treating the immediate presentation as an isolated event. Insufficient account was given to the risk of ongoing attacks and other complications arising.


The Inquest heard that the general practice and the Trust involved in this case have taken a number of steps to improve the care provided to asthma patients. The Inquest, however, heard from a number of witnesses that there are concerns about the care provided to asthma patients nationally.


Case background


Kalila Griffiths had complex medical history including, asthma, Ehlers-Danlos syndrome and postural tachycardia syndrome. In December 2018 she developed shortness of breath. She attended her GP surgery on the 4th of January 2019. The GP prescribed medication for a chest infection and for asthma. Despite this treatment, Kalila’s respiratory health deteriorated during January 2019 rendering her largely unable to mobilise. She was confined to her bedroom for most of January 2019. Kalila required at least four attendances at her GP practice and two attendances to A & E (6th and 19th of January). The second A&E attendance – 19th of January 2019 – followed a life-threatening deterioration in her breathing. Kalila had recorded an oxygen saturation of 74% prior to presentation at the hospital. She had been unable to speak to the 111 operator and she could be heard with a continuous cough in the background. Notwithstanding her poor clinical state, she was discharged from the hospital without the required observation; clinical assessment and history gathering. She required admission to the hospital at this time, for assessment by a respiratory physician.


Coroner Persaud has said that had she received observation in hospital and assessment by a respiratory physician on the 19th January 2019, on the balance of probabilities her death would have been avoided.


Coroner’s comments


Commenting on the case Miss N Persaud, a senior coroner in East London said the following:


“Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented. The recommendations of importance in this case were:


  • Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve.
  • Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma.
  • Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve.
  • Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer.


“Clinicians raised concerns in relation to the number of different guidelines relating to asthma (NICE Guidelines, BTS/SIGN Guidelines and GINA Guidelines). It was noted that there are discrepancies between the guidelines. This makes it difficult for those general practitioners and emergency care practitioners who are providing care to patients.


“It was noted that it is not clear to healthcare professionals which guidelines should be used for the management of acute asthma attacks. Many clinicians consider that NICE guidelines can be used for the management of an acute asthma flare-up. The Inquest heard that this is incorrect and that the BTS SIGN guidelines should be used.


“The evidence revealed that further training is required for GPs and emergency departments in providing safe asthma care.”


This coroner’s report is damning of many of the current approaches to caring for people with asthma. If you are involved in caring for people with asthma we would really value your opinion and insights below. We must try our best to make sure we all work hard to make sure cases like this one stop happening. Thank you for your contribution in advance.


Very best wishes as ever,





Elements of this article are being shared under the Open Government Copyright licence.


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PIP editor

A pharmacist led training provider.

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