Royal Free Hospital ‘could have saved’ boy who died of asthma attack after being sent home by doctors
PUBLISHED: 11:02 18 March 2017 | UPDATED: 12:30 18 March 2017
Young chess champion Michael Uriely died from chronic asthma on August 25 2015 - five days after being discharged from the Hampstead hospital by medics.
Westminster Coroner’s Court heard that Michael, from St John’s Wood, was repeatedly seen by doctors, including an NHS GP, private paediatrician and hospital staff, in the months before his death.
Despite the frantic efforts of his parents, Ayelet and Roy, they all failed to diagnose him with chronic asthma and missed 11 opportunities that could have saved his young life.
Coroner Dr Shirley Radcliffe said that if the Royal Free had kept him in for treatment instead of sending him home for a second time, he might not have died.
In her conclusions on Thursday - two days after what would have been Michael’s 11th birthday - she made a national recommendation to try to prevent future similar deaths.
Seven other children in London have died from asthma since Michael’s death, the inquest was told.
Expert respiratory paediatrician Dr Richard Iles said Michael’s death was preventable and he should have been referred to a specialist.
He said there were a number of clear signs that the care programme was not working months earlier.
Westminster school pupil Michael was taken to the Royal Free Hospital, in Pond Street, on August 18 after he suffered violent coughing and vomiting fits which left him struggling to breathe.
He was discharged at 8pm the same day.
His frantic parents rushed him back to A&E after he suffered another severe attack during the early hours of the morning on August 19.
He was kept in overnight before being sent home again the following day.
Dr Radcliffe concluded that if Michael had remained in hospital on a high dose of steroids with a referral to a respiratory specialist “it’s unlikely he would have died”.
She said that by the second attendance at A&E in 24 hours “alarm bells should have begun to ring”.
She added that a “totally inadequate history was obtained” after the paediatrician who treated him on the second admission failed to realise he had been there the previous day.
“The opportunity was lost to recognise this as a serious problem - the history and signs were there to be seen and understood.
“But sadly it wasn’t recognised and he was discharged essentially on the same treatment he had been on,” she added.
The Royal Free Hospital carried out two internal investigations after Michael’s death and concluded that staff failed to diagnose him with chronic asthma and the care he was given was not adequate.
The hospital has since appointed two specialist respiratory clinicians, opened a dedicated asthma clinic and implemented a new strategy for treating children with asthma.
Michael died from an acute asthma attack, the coroner ruled.
Michael’s mother Ayelet Uriely said in a statement she was “devastated beyond words” about the loss of her son, a national chess champion who she described as “highly gifted”.
He was diagnosed with asthma when he was two-and-a-half years old and began learning how to play chess around six months later, competing at local, regional and then national level as he grew up.
The inquest had heard that Mrs Uriely “felt strongly” her son was denied basic care.
On August 18 when she took him to the Royal Free, Mrs Uriely said she thought he was having his worst ever asthma attack.
But she said she was told: “You don’t really need to be here. You should go home.”
Mrs Uriely said they were told “something like we were wasting their time”, and that Michael would grow out of asthma.
He was brought back to the hospital in the early hours of August 19, but by this stage was having violent bouts of vomiting and bloated chest.
The inquest had heard he was told he was “hysterical” and not having an asthma attack.
Mrs Uriely was told he was being discharged that afternoon but she said she told staff: “I am scared my son will die tonight”. She also said Michael himself said he was “afraid to die”.
She told the inquest: “I said: ‘I’d never let anything bad happen to you.’”
After the verdict, his parents said they were devastated and described their son as “an extraordinary boy, both in personality and intelligence”.
“He doted on his younger twin sisters, who adored him, and always joined in with their games,” they said in a statement.
“Michael was highly gifted with a tendency to excel.”
They said the inquest “has now gone some way” in providing answers to their questions and added that lessons should be learned “so no other child’s life is cut short and no other parent feels the same despair”.
To mark what would have been Michael’s tenth birthday on March 14, last year Roy and Ayelet hosted a chess tournament at his school Westminster Under on April 17 which raised £10,400 for charity Asthma UK. See here.