A teenager tragically died after doctors failed to spot she was having her first ever asthma attack and ‘inappropriately’ discharged her back home.
Billie Wicks, 16, was rushed by her concerned parents to the Royal Free Hospital in Hampstead, north London, last September, but doctors did not carry out observations or reviews that would probably have saved her life, a coroner found.
It was a busy night in the A&E department at the hospital, and the coroner noted how the department was ‘understaffed’ on the night Billie was there.
Instead, NHS staff ‘safety netted’ the teenager, reassuring the family as they discharged her in the early hours of the morning that they could bring her back in ‘if they had any concerns’.
However, this advice meant that when her condition later deteriorated, Billie’s parents’ ‘natural instincts’ to seek medical help were ‘blunted’, the coroner said.
The teenager died the following day on September 15, 2024, and an inquest into her death was opened two days later.
Mary Hassell, coroner for Inner North London, has now written to the Royal Free Hospital in Hampstead warning that more people could die unless action is taken.
The inquest was told that Billie was taken to the hospital’s A&E in September 2023 just before midnight on the night before her death with an asthma attack.
She had never suffered from the condition before, the inquest was told.
‘A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department,’ Ms Hassell wrote.
‘Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated.
‘If it had been, she probably would have survived.’
At the inquest, Ms Hassell recorded a narrative conclusion that Billie died from ‘infective exacerbation of asthma’.
In her Prevention of Future Deaths report, she raised a number of concerns.
‘At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations,’ she wrote.
‘Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review.
‘That senior medical review would have changed the course of her management and saved her life.
‘The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion.
‘This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.
‘At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need.’
Meanwhile, Ms Hassell also mentioned the case of Daniel Klosi, 4, – who died from sepsis at the Royal Free in 2023.
Daniel was taken to hospital four times in the week running up to his death, and a report into the circumstances surrounding his death also raises concern about observations.
‘Following the inquest touching the death of Daniel Klosi, I wrote to you on August 16 2024 about a lack of observations in the emergency department of the Royal Free.
‘Although the circumstances were different, there is a theme,’ Ms Hassell said.
Ms Hassell additionally raised concerns about the NHS practice of ‘safety netting’ – where information is given to a patient or their carer about actions to take if their condition fails to improve.
‘I heard that Billie was safety netted when she was discharged,’ she wrote. ‘Her parents were told to bring her back if they had any concerns.
‘I have heard this safety netting advice being described many, many times in different inquests.
‘What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff.
‘It is therefore difficult to see how this particular advice could be a meaningful instruction.
‘In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital.
‘When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital.
‘In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.’
As well as the Royal Free, Ms Hassell addressed her concerns to the Royal College of Paediatrics and Child Health and the Royal College of Emergency Medicine.
They have until the May 12 to respond.
A spokesperson for the Royal Free London said: ‘We would like to share our heartfelt condolences with Billie’s family and to say how sorry we are that she died while under our care.
‘Following an investigation into the care provided to Billie, we have taken steps to increase staffing levels in the children’s emergency department during nights and weekends and improve the process for alerting senior clinicians when an abnormal test result is received.
‘We will carefully review the coroner’s findings and respond to all the matters she has raised.’
