Key findings of the NRAD
| 1) 195 (71%) out of 276 cases considered by the panels died from asthma; and 27 (10%) had no evidence in their records confirming that they had asthma. |
| 2) The panels concluded that overall asthma management (acute and chronic) was satisfactory in only 31 (16%) out of 195 people who died, and in only one (4%) of the 28 children and young people. |
| 3) The panels identified at least one major potential avoidable factor in 130 (67%) cases out of the 195 who died from asthma. |
| 4) 45% of those who died from asthma either did not call for or receive medical assistance in their final fatal attack. This surprise finding was coupled with the observation that 77% of those who died had no evidence in their medical records of being provided with a PAAP detailing how their medication was to be taken, how to recognise danger signals and when to call for help. |
| 5) The panels identified a number of missed opportunities by the healthcare professionals to intervene and reduce the risk of asthma attacks and death. These were related to: |
| a) Prescribing issues; with overprescribing of short-acting reliever inhalers (SABA) and insufficient provision of inhaled corticosteroid preventer medication |
| b) Failure to monitor asthma control and to provide follow-up assessment and optimisation of medication after asthma attacks; irrespective of whether these were treated in hospital or the community by primary care clinicians |
| c) Failure to refer patients to an asthma specialist (within hospital and from primary care) |
| d) There were potentially avoidable factors related to non-implementation of the current UK BTS/SIGN asthma guidelines [3] in 89 (46%) out of the 195 deaths |
BTS: British Thoracic Society; SIGN: Scottish Intercollegiate Guidelines Network.