The death of a 10-year-old boy with a "heart of gold" who suffered an asthma attack was "avoidable", a coroner has concluded.
William Gray died in March 2021 following "multiple failures" from health professionals in Essex who "significantly" under-estimated the nature of his condition between a first asthma attack and the one that killed him, an inquest heard.
Essex assistant coroner Sonia Hayes concluded that "record-keeping was minimal, contact was minimal and William's voice was nowhere to be heard," adding that the youngster was "neglected" by health services.
The evidence heard during the 10-day inquest will be used to improve training for treating children suffering a life-threatening asthma attacks and ensure that nationwide guidance to paramedics is clear.
After suffering an asthma attack in 2020 that left him "as near to death as possible without dying", William was dismissed from A&E at Southend Hospital after four hours.
The coroner said this "should not have taken place" and his condition should have generated "more medical curiosity".
His family then had an "absence of contact for four months" during which they pressured local NHS services to improve his medication but found "no urgency" from health professionals to refer him to a specialist service.
The inquest found that asthma nurses had telephone calls with the family that lasted "a matter of minutes" and were "not meaningful".
On 29 May 2021, William suffered a fatal asthma attack. Ms Hayes said that paramedics who attended had a "lack of awareness" about his condition.
She added that the 999 call made by William's mother Christine Hui should have been made a Category 1 call and he should have received adrenaline sooner, as he was only given it when in the ambulance.
In a statement read to the court, Ms Hui said: “It was chaotic, but at the same time there was no real urgency about getting William to hospital.”
There was also a "significant delay" in the adrenaline being given after he went into cardiac arrest.
In her concluding remarks, Ms Hayes said that William's condition could have been prevented.
She said: "William's death was contributed to by neglect. William's death was avoidable.
"There were multiple failures to escalate and treat William's very poorly controlled asthma by healthcare professionals that would and should have saved William's life."
'Parents know their children best'
Speaking after the hearing, Ms Hui said she hoped health services could learn lessons from her son's death.
"We believed that William’s asthma was controlled, but now we know that wasn’t the case," she said in a statement released through the family's lawyers Leigh Day.
"Parents know their children best and should trust their instincts. If you feel something isn’t right, question it."
She added: "There is nothing that can take away the grief our family feels, but it is our hope that another family will hear our story and it could prevent a further tragedy.
"This is the final stage in saying goodbye to our son, brother, grandson, great grandson, nephew and friend.
"William was a funny, caring little boy who liked to make jokes and had a heart of gold. He was adored by his friends. He had dreams of working in medicine as a doctor or a paramedic because he saw the care he was given, and he wanted to do that for others."
'Committed to learning from this terrible loss'
Diane Sarkar, from the Mid and South Essex NHS Foundation Trust, which runs Southend Hospital, said the trust's "heartfelt condolences" went to the family.
She added: “We’d like to assure them that we are committed to learning from this terrible loss and that since his death in 2021 we have brought in numerous changes to improve patient care as a direct result of learning from William’s case."
Melissa Dowdeswell, from the East of England Ambulance Service Trust, said: “We accept the coroner’s findings and will assess what further actions need to be taken once we have reviewed them.
“Since this tragic case we have significantly increased the numbers of staff able to perform intubation and these numbers continue to rise with an expansion of advanced paramedics within the trust.
"Our heartfelt condolences go out to William’s family and our thoughts remain with them at this difficult time."
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