AvMA case study: M's story

Summary

M was a young boy who had severe asthma, resulting in regular trips to A&E. His condition was eventually well controlled with a Seretide inhaler. When M's family moved house and changed their GP, they requested a new prescription of Seretide, but when they got to the pharmacy were given the wrong type of inhaler used to treat a different form of asthma. The GP had unwittingly chosen the wrong medication from a drop-down menu. M and his family were unaware that he was taking the wrong medication, and after a few days, M became breathless and his family decided to take him to hospital. Sadly, he died on the journey to A&E.

At the inquest, the Coroner found that there two main issues that contributed to M’s death:

• the unintentional prescription of Serevent
• the failure to arrange and organise follow up contributed to M’s death.