A lack of co-ordination by health professionals contributed to the death of a teenage girl from an asthma attack, a coroner has ruled.
Life-long asthma sufferer Tamara Mills, who lived on the Woodbine Estate, South Shields, died at South Tyneside District Hospital on April 11, last year after being taken to the accident and emergency department.
The 13-year-old suffered a cardiac arrest following an asthma attack and could not be saved.
At the conclusion of an inquest into her death, South Tyneside coroner Terence Carney ruled: “The premature death of this young woman was contributed to by a lack of appreciation and or reaction to the deteriorating nature of her chronic condition and to the absence of any planning to direct, monitor, manage and co-ordinate her care.”
He said: “This condition was not, even as severe as it was and as chronic as it was, in itself a death sentence.
“It should not have been.”
The premature death of this young woman was contributed to by a lack of appreciation and or reaction to the deteriorating nature of her chronic condition and to the absence of any planning to direct, monitor, manage and co-ordinate her care.Terence Carney, South Tyneside coroner
Earlier in the hearing, Dr Georgina McCann, a GP at the Farnham Medical Centre, in Stanhope Road, South Shields, where Tamara was a patient, admitted there had been “a failure to recognise” the practice’s role in Tamara’s treatment and that they “missed picking up on the high risk state of her asthma”.
The inquest also heard that Tamara was never referred to specialist respiratory care.
Dr Shaun Sandbach, a GP and senior partner at Farnham Medical Centre, told the hearing that “in retrospect” they should have done it.
The hearing was also told that Dr Katherine Eastham, a consultant paediatrician with special interest in respiratory paediatrics at Sunderland Royal Hospital, had written to consultant paediatrician Dr Gabriel Okugbeni, director for paediatrics at South Tyneside District Hospital and the lead clinician caring for Tamara, offering to see the teenager in her specialist clinic.
This followed Tamara suffering a near-fatal asthma attack in November 2013.
She never heard back from him.
Dr Okugbeni told the inquest that he didn’t refer Tamara – who had been working to lose weight – because he feared the steroids she would be prescribed would cause her to gain weight.
The hearing also heard that Dr Eastham had prepared an emergency plan for Tamara in the event of another serious asthma attack, but that there was no plan for her continuing care.
Mr Carney said that the focus on Tamara’s care was to treat her each time she had an attack rather than in the continuation of her care and preventing future attacks.
During his narrative finding, Mr Carney praised changes which have been made at Farnham Medical Centre, such as the appointment of an asthma lead, since Tamara’s death.
But said that more could be done to co-ordinate the care of complex cases being dealt with on both GPs and hospital doctors and that work should be done to “formulate links”.
Mr Carney said he planned to write to the local Clinical Commissioning Group with his concerns.
Tamara’s mother, Dawn Wilson, wished to make no comment after the hearing.