1. National Review of Asthma Deaths (NRAD) www.rcplondon.ac.uk/NRAD
Why asthma still kills
National Review of Asthma Deaths (NRAD)
Mark L Levy FRCGP Clinical Lead, NRAD
Rachael Andrews NRAD programme coordinator, Royal College of Physicians (RCP)
Rhona Buckingham Operations director, Clinical Effectiveness and Evaluation Unit (CEEU), Royal College of Physicians (RCP)
Hannah Evans Medical statistician, Royal College of Physicians (RCP)
Caia Francis Senior lecturer in adult nursing, University of the West of England, and former chair, respiratory forum,
Royal College of Nursing (RCN)
Rosie Houston NRAD programme manager, Royal College of Physicians (RCP) (until February 2013)
Derek Lowe Medical statistician, Royal College of Physicians (RCP)
Dr Shuaib Nasser Consultant allergist and respiratory physician; British Society for Allergy and Clinical Immunology (BSACI);
Eastern Region Confidential Enquiry of Asthma Deaths
Dr James Y Paton Reader in paediatric respiratory medicine, Royal College of Paediatrics and Child Health (RCPCH)
Navin Puri Programme manager for respiratory medicine

2. National Review of Asthma Deaths
Commissioned by: Healthcare Quality Improvement Partnership (HQIP) On behalf of: NHS England, NHS Wales, Health and Social Care Division of the Scottish Government, Northern Ireland Department of Health Social Services and Public Safety Delivered by: Clinical Effectiveness and Evaluation Unit of the Clinical Standards Department of the Royal College of Physicians

3. Eastern Region Confidential Enquiry of Asthma Deaths
Supporting partners
Eastern Region Confidential Enquiry of Asthma Deaths

4. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Panel Conclusions & Avoidable factors Key messages Key recommendations Acknowledgements

5. Overall aim of NRAD
The aim of the NRAD was to understand the circumstances surrounding asthma deaths in the UK, in order to identify avoidable factors and make recommendations for changes to improve asthma care as well as patient self-management
(This was not a prevalence study – did not aim to determine the number of asthma deaths in the UK)

6. Objectives of the NRAD
Conduct a multidisciplinary, confidential enquiry of asthma deaths Feb Jan 2013
effectiveness of the management of asthma (acute and chronic)
Identify potential avoidable factors
Make recommendations for changes - to reduce the number of preventable asthma deaths
Understand the effect of asthma and death from asthma on families and carers
The aim of the NRAD was to understand the circumstances surrounding asthma deaths in the UK, in
order to identify avoidable factors and make recommendations for changes to improve asthma care as
well as patient self-management.
Objectives
1 Conduct a multidisciplinary, confidential enquiry to investigate the circumstances and clarify the cause
of death in those people meeting the study inclusion criteria.
2 Examine the effectiveness of the management of asthma by reviewing the quality of care during the
fatal attack, as well as previous treatment, against standards derived principally from the British
Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) British Guideline on the
Management of Asthma (2012).1
3 Identify potentially avoidable factors related to the circumstances of those asthma deaths.
4 Make recommendations for changes in clinical management in order to reduce the number of
preventable deaths from asthma in the future.
5 Understand the effect of asthma and death from asthma on families and carers of people with asthma
by interviewing bereaved relatives on their experiences of the care provided to the family member who
died.

7. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Panel Conclusions & Avoidable factors Key messages Key recommendations Acknowledgements

8. Underlying cause of death
On the basis of what is written on the Medical Certificate of the Cause of Death (MCCD), the Office for National Statistics (ONS), National Records of Scotland (NRS), Northern Ireland Statistics and Research Agency (NISRA) then determine the underlying cause of death. Based on the formula used world wide for this purpose - International Classification of Disease (ICD) So where an MCCD reads: The underlying cause of death (UCD) is determined to be Asthma The underlying cause of death (UCD) is also Asthma
Ia Respiratory Failure
Ib Asthma
Ic Chest infection
Ia Chest infection
II Asthma, IBS, Liver failure, sepsis OR

9. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Panel Conclusions & Avoidable factors Key messages Key recommendations Acknowledgements

10. NRAD Notification (Section 251 of the NHS Act 2006)
Office for National Statistics (ONS); National Records of Scotland (NRS); Northern Ireland Statistics and Research Agency (NISRA).
NRAD Website
Clinicians
Families / Friends
Coroners
Local co-ordinators
(374 in 297 Hospitals)

11. Asthma mentions MCCD* (3544) Confidential enquiry (276)
NRAD flow diagram - 1
Asthma mentions MCCD* (3544)
Excluded – not underlying cause of death or >75 and asthma in part II (2644)
Included (900)
No data (145)
Insufficient data (127)
Not asthma (352)
Confidential enquiry (276)
* MCCD= Medical Certificate of Cause of Death

12. Clinical information requested for final 2 years (n=900)
ALL CONSULTATIONS
ALL CORRESPONDENCE
ALL PRESCRIPTIONS (ACUTE & REPEAT)
PM/CORONERS REPORT/AMBULANCE
COPIES OF ANY LOCAL REVIEWS

13. NRAD flow diagram - 2 Clinical Lead & Expert panel
Asthma mentions MCCD (3544)
Excluded – not underlying cause of death or >75 and asthma in part II (2644)
Included (900)
No data (145; 16%)
Insufficient data (127; 14%)
Not asthma (352; 39%)
Confidential enquiry (276; 31%)
Clinical Lead
Clinical Lead supported by expert panel decided whether to include cases (possible asthma deaths) in the Confidential Enquiry
& Expert panel

14. NRAD flow diagram - 3 Asthma mentions MCCD (3544)
Excluded – not underlying cause of death or >75 and asthma in part II (2644)
Included (900)
No data (145; 16%)
Insufficient data (127; 14%)
Not asthma death (352; 39%)
Confidential enquiry (276; 31%)

15. Multidisciplinary confidential enquiry panels
37 panel meetings
174 volunteer assessors
6 -10 cases per panel
Two assessors per case
Panel assessment form
Consensus agreement
195/276 died from asthma
1000 panel recommendations
Major factors in 60% deaths potentially avoidable

16. Sources of data
MCCDs ONS/NISRA/NRS
Panel assessor conclusions and potential avoidable factors
Information provided by clinicians
Audit data extracted from medical records
Clinical notes (primary & secondary care & paramedics)
Post mortem reports
Audit data and Panel conclusions … therefore denominators vary in the report

17. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Key messages Key recommendations Acknowledgements

18. LOCATION OF DEATH

19. Patients
Duration of asthma (n=104) : 0-62 yrs (Median 11 yrs) Age at diagnosis (n=102) : 10 mths – 90 yrs (Median 37 yrs) Age at death (n=193) : 4 yrs – 97 yrs (Median 58 yrs) Severity of asthma (n=155): (classified by the Clinicians) Mild 14 (9%) Moderate 76 (49%) Severe 61 (39%)

20. Definition of severity of asthma:
‘Amount of treatment required to gain control of the asthma’
European respiratory Journal 2008;32(3):545-54

21. Mild / Moderate Asthma - 58% of those who died from asthma
It is possible that many of those cases defined by their doctors as Mild or Moderate ….. were more severe

22. Case review 1 (from a number of cases - for annonymity)
Middle aged male … asthma diagnosed in childhood
Classified by GP with mild asthma
Last asthma review 2 years before death
symptoms most days; Rx - salbutamol 2-3 times most days
PEF 120 (previous best 260, predicted 426)
Dr added beclometasone 100mcg bd
Failed to attend review appointment for follow-up
….. but seen twice by GP for unrelated symptoms in next two months
(from a number of cases - for annonymity)

23. Case review 1 (continued)
8 months before death: Attended GP
breathlessness and wheeziness. Rx antibiotic only
Seen 3 times subsequently for arthritis symptoms
Died at home few months later
post mortem examination : Ia Acute asthma
During his last year of life
salbutamol inhalers : 18 prescriptions
beclometasone 100mcg (200 doses) : 1 prescription
Did he really have mild asthma?
It is possible that many of those cases defined by their doctors as Mild or Moderate ….. were more severe

24. Primary care of the 195 cases (in the 12 months before death)
64 (33%) - no details on asthma diagnosis
70/ diagnosed > age of 15
? Late onset; ? Delayed diagnosis; ? Recurrence
84 (43%) - no record of asthma review 12 mths
37 (19%) - had assessment of asthma control
44 (23%) - had Personal Asthma Action Plans (PAAP)
112 (57%) - not under specialist supervision
One-hundred (51%) of the 195 patients that died were diagnosed on the basis of recurrent symptoms, 34 (17%) on physiological measurement of lung function, and 66 (34%) on the response to asthma medication. The basis for diagnosing asthma was not detailed in 64 (33%).

25. Excessive GP prescribing of Short Acting Beta-Agonist Bronchodilators (SABAs) (n= 189/194 ; 97%)
Excess need for reliever medication (SIGN/BTS) = Poor asthma control
Numbers of devices prescribed during final year (n=165)
Range: 1 to 112; median of 10 inhaler devices
> 6 SABA : 92/165 (56%) inhaler devices
> 12 SABA : 65/165 (39%) inhaler devices
>50 SABA : 6 patients
From available information on 194 of the 195 cases who died, 189 (97%) were recorded as having SABAs prescribed at the time of death. Of these 189, there were 165 for whom the number of prescriptions authorised for SABA was recorded within the last year, and of these 3 were recorded as zero. For the 162 with one or more within the last year the number of prescribed devices ranged from 1 to 112, with a median of 10 (IQR 3,21) inhalers per year. Ninety two (57%) of the 162 were prescribed more than six SABA inhalers and 65 (40%) more

26. Inadequate GP prescribing of Inhaled Corticosteroids (ICS) ICS alone or in combination with Long Acting Beta-agonist Bronchodilator (ICS/LABA) (n= 168/195 ; 86%)
Number of prescribed devices final year (n=128):
Range: 1 to 54, median of 5 inhaler devices
< 4 ICS devices in 12 mths : 49/128 (38%)
< 12 ICS devices in 12 mths : 103/128 (80%)
From available information, 168 (86%) of the 195 that died from asthma had repeat prescriptions authorised for inhalers containing inhaled corticosteroids, either as ‘stand alone’ ICS and / or as combination ICS/LABA inhalers at the time of death. Conversely, 26 (13%) of the 195 cases were not prescribed any preventer medication at all in their final year, with insufficient information for the remaining 1 case.
Depending on the dose of medication and device prescribed patients would normally need about 12 ICS or ICS / LABA combination inhaler devices a year, in order to adhere to advice on daily medication use. For 128 of the 168 cases the number prescribed ICS alone and the number prescribed combination ICS / LABA inhalers in the 12 months before they died were both known. These 128 cases were prescribed a median of five inhalers IQR (2,10), and the numbers of inhalers prescribed for cases ranged from one to 54 inhalers in the twelve months. Forty nine (38%) of these 128 cases had been issued (and presumably collected) less than four prescriptions for these inhaler devices in the 12 months before death, and 103 (80%) were prescribed less than 12 inhalers, and as most ICS or ICS / LABA combination inhalers last for 1 month at standard doses, the majority of cases were therefore undertreated and had only partially adhered to medical advice.

27. Prescribing NRAD Recommendation:
Electronic surveillance of prescribing in primary care to alert clinicians and pharmacists -excessive Short Acting Beta-Agonist Bronchodilators (SABAs) or too few preventers

28. Practices (denominator = 138 except where mentioned otherwise)
Median 4 Doctors/practice (n=131); median 9000 patients
Quality Outcomes Framework (QOF) data (n=89)
Full points 74/89 (83%)
Asthma reviews - performed by:
78/136 (57%) GPs
3 (2%) GP with Special Interest
82 (60%) Nurses with diploma
62 (46%) nurses without asthma diplomas *
These practices had a median of 4 doctors IQR (3,5) n=131 returns, and cared for a median 9500, IQR (6250,12000) patients, n= 134 returns. Thirteen (10%) of 131 of the practices had only one full time doctor, 9 of whom employed between one and six part time doctors.
Thirty eight (28%) of 135 practices said they had a doctor with a special interest in respiratory diseases. One hundred (81%) of 124 practices who returned data 100 (81%) employed at least one nurse known to have an asthma diploma. Fifty seven (41%) of 138 practices provided student teaching and GP postgraduate training, and 15 (11%) of 138 were research practices.
for 89/138 (64%) of the 195 people who died from asthma; full points (i.e. 45 points) were attained by 74 (83%) of the 89 practices, with a median of 45, IQR (45,45 points) for these 89 practices.
Asthma reviews were said to be performed by GPs in 78 (57%) of 136 practices, by GPs with an interest in respiratory diseases in 3 (2%), by nurses with an asthma diploma in 82 (60%) and by ‘general’ practice nurses in 62 (46%),

29. Case review 2 – Asthma review without action (from a number of cases - for annonymity)
Female with late onset asthma
Confirmation of diagnosis delayed - after many months on therapy with intermittent salbutamol (28% reversibility on spirometry)
Low dose inhaled corticosteroids (beclometasone 100mcg)
Asthma review with practice nurse
Waking at night; daytime symptoms and asthma limited her lifestyle
Px last 12 months: 16 salbutamol inhalers; 1 beclometasone inhaler
Nurse advised patient to make an appointment to see the doctor
The patient died 8 weeks later without ever making an appointment to be seen

30. Case review 2 (continued) : Issues
Quality Outcomes Framework (QOF) - tick box process?
Delegation appropriate?
Training
NRAD Recommendations:
Annual structured review by a healthcare professional with specialist training in asthma
Assess asthma control at every asthma review. Where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up

31. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Panel Conclusions & Avoidable factors Key messages Key recommendations Acknowledgements

32. Main conclusions for the 276 cases considered by panels
People who died from asthma
195 (71)
People who did not have asthma
27 (10)
People who had asthma but did not die from it
36 (13)
Insufficient information:
- To decide whether the person had asthma
14 (5)
- To decide whether the person died of asthma
4 (1)

33. Overall assessment by panels: Quality of care
All 195 (Adequate)
n(%)
< 20 years (n=28)
(adequate)
a) Quality of care: Routine/chronic management
56 (29)
2 (7)
b) Quality of care: Management of attacks in the past
69 (35)
8 (29)
c) Quality of care: Management of the final attack
66 (34)
13 (46)
d) Overall standard of asthma care for the patient
Good practice
31 (16)
1 (4)
Room for improvement - aspects of clinical care
51 (26)
Room for improvement - aspects of organisational care
6 (3)
Room for improvement - aspects of clinical and organisational care
45 (23)
3 (11)
Less than satisfactory several aspects of clinical and /or organisational care were well below a standard one would expect

34. Overall assessment by panels: Quality and standard of care
All 195 (Adequate)
n(%)
< 20 years (n=28)
(adequate)
a) Quality of care: Routine/chronic management
56 (29)
2 (7)
b) Quality of care: Management of attacks in the past
69 (35)
8 (29)
c) Quality of care: Management of the final attack
66 (34)
13 (46)
d) Overall standard of asthma care for the patient
Good practice
31 (16)
1 (4)
Room for improvement - aspects of clinical care
51 (26)
Room for improvement - aspects of organisational care
6 (3)
Room for improvement - aspects of clinical and organisational care
45 (23)
3 (11)
Less than satisfactory several aspects of clinical and /or organisational care were well below a standard one would expect

35. Major factors identified by panels (i. e
Major factors identified by panels (i.e. contributed significantly to the deaths, where different management would reasonably be expected to have affected the outcome ) n
Did not recognise high-risk status 21
Lack of specific asthma expertise 17
Did not perform adequate asthma review 16
Did not refer to another appropriate team member
Failure to take appropriate medication in month before death 15
Failure to take appropriate medication in year before death
13 
Over prescribed short acting beta agonist bronchodilator 13
Poor or inadequate implementation of policy/pathway/protocol
Lack of knowledge of guidelines 12
Did not adhere to medical advice 10

36. Potential avoidable factors identified by panels related to the patient their family and the environment
All ages
(n=195)
n(%)
< 10 yrs
(n=10)
10-19 yrs
(n=18)
One or more avoidable factors
126(65)
9(90)
17(90)
Poor adherence to advice
94(48)
13(72)
Psychosocial factors
51(26)
3(30)
4(22)
Smoker or exposed to second hand smoke
47(24)
(7(39)
Allergy
23(12)
2(20)
7(39)
NRAD Recommendation:
Parents and children and those who care for them should be educated about managing asthma

37. Potential avoidable factors identified by panels in routine medical care and ongoing supervision and monitoring
Primary Care (n=195)
n(%)
Secondary Care (n=83)
One or more avoidable factors
137 (70)
24 (29)
Avoidable prescribing factor
92 (47)
12 (14)
Lack of adherence to guidelines
115 (59)
19 (23)
NRAD Recommendation:
Health Care Professionals should be aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues.

38. The panels identified potential avoidable factors related to the assessment of the final attack
Primary Care (n=38)
n(%)
Secondary Care (n=59)
< 10 yrs Sec Care
(n=2)
10-19 yrs Sec Care (n=5)
≥ 1 factors
13(34)
20(34)
1(50)
1(20)
NRAD Recommendation:
Every NHS hospital and general practice - clinical lead for asthma services responsible for formal training in acute asthma care

39. The panels identified potential avoidable factors related to the management of the final attack
Primary Care (n=38)
n(%)
Secondary Care (n=59)
< 10 sec care
(n=2)
prim care
(n=1)
sec care
(n=5)
≥ 1 factors
12(32)
20(34)
1(50)
1(100)
2(40)
Delay or failure : to initiate treatment / to follow guidelines
Use of NIV in acute severe asthma
Failure to recognise risk features (High normal pCO2 levels)
NRAD Recommendation:
Every NHS hospital and general practice - clinical lead for asthma services responsible for formal training in acute asthma care
The use of patient-held ‘rescue’ medications should be considered for all patients who have had a life-threatening asthma attack or a near fatal episode

40. The panels identified potential avoidable factors related to follow-up after attacks
19/195 (10%) died within 28 days of hospital admission for asthma attack
In 13/19 (68%) potentially avoidable factors
discharge into the community
follow-up arrangements
At least 40 (21%) attended an emergency department (ED) with an asthma attack in the previous year (23 ≥ 2 occasions)
NRAD Recommendations – follow-up and referral:
Follow-up after every attendance for an asthma attack
Secondary care follow-up - after every hospital admission for asthma, and after two or more ED visits with an asthma attack in 12 mths
Patients with > 2 courses systemic corticosteroids or on BTS step 4/5 must be referred to a specialist asthma service
Nineteen (10%) of those who died did so within 28 days of being treated in hospital for an asthma attack. In 13 (68%) of these patients the panels identified potentially avoidable factors in relation to both their discharge into the community and follow-up arrangements. At least 40 (21%) of those who died had attended an emergency department (ED) with an asthma attack in the previous year and of these 23 had attended on at least two occasions.
According to national standards people admitted to hospital with an acute exacerbation of asthma should have a structured review by a member of a specialist respiratory team before discharge.1, 2, 43-47

41. Environmental data (more detailed analysis planned)
Limitation due to absence of comparative asthma death data for 2011
Fungal spore data:
There were low levels of alternaria & cladosporium in 2012
There wasn’t a summer peak of asthma deaths
NRAD data supports the association between summer deaths and these spores

42. Family interviews
Approval to conduct family interviews was obtained in 2011 from the National Research Ethics Committee (NREC) reference 1522/NOCI/2012
There were extraordinary delays in securing local research and development (R&D) and permission was only achieved from 66 (28%) of 238 approached nationally
There were difficulties approaching families
Insufficient numbers of interviews were conducted to obtain meaningful, generalisable information

43. Post mortem analysis Planned publication as a separate paper
Data available on the RCP website as appendix

44. Health professionals were asked to submit copies of any local reviews on their patients who died
Received for 24/195 (12%)
12 / 28 (43%) children and young people
12 / 118 (10%) aged 20–74 years
Panels concluded 9 / 24 (38%) reviews were of adequate quality for reflective learning
NRAD Recommendation:
In all cases where asthma is considered to be the cause of death, there should be a structured local critical incident review in primary care (to include secondary care if appropriate) with help from a clinician with relevant expertise

45. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Panel Conclusions & Avoidable factors Key messages Key recommendations Acknowledgements

46. NRAD Key Messages 1: Failure to get help in time
45% of people died without calling for or getting medical help
80% of children and 73% young people died before they reached hospital
NRAD Recommendation: All people with asthma - personal asthma action plan (PAAP) – why, how & when to take medication and when & how to call for help

47. Health care utilisation
NRAD Key Messages 2 : Failure by doctors, nurses, patients and carers to identify risk - missed opportunities
Prescribing
Excess relievers ; insufficient preventers
Health care utilisation
10% recent admission
21% ED
NRAD Recommendations: electronic monitoring prescriptions; earlier specialist referral; follow-up; named clinician responsible in hospital and primary care

48. NRAD Key Messages 3: Assess and gain asthma control
58% (90/155) treated for mild / moderate asthma
BTS/SIGN Guidelines not implemented in 46% (89/195)
NRAD Recommendation:
Assess asthma control at every annual asthma review. Where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up

49. Lecture plan – NRAD Report
Aim & Objectives Death Certification Methodology Demographics and audit data Panel Conclusions & Avoidable factors Key messages Key recommendations Acknowledgements

50. Key recommendations 1: Organisation of NHS services
Every NHS hospital and general practice - clinical lead for asthma services
Patients with > 2 courses systemic corticosteroids or on BTS step 4/5 must be referred to a specialist asthma
Follow-up arrangements :
after every attendance for an asthma attack
Secondary care follow-up - after every hospital admission for asthma, and after two or more times ED visits with an asthma attack in 12 mths
A standard national asthma template
Electronic surveillance of prescribing in primary care to alert clinicians (excessive SABAs or too few preventers
A national ongoing audit of asthma
Every NHS hospital and general practice should have a designated, named clinical lead for asthma services, responsible for formal training in the management of acute asthma.
Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids, oral or injected, in the previous 12 months or require management using British Thoracic Society (BTS) stepwise treatment 4 or 5 to achieve control.1
Follow-up arrangements must be made after every attendance at an emergency department or out-of-hours service for an asthma attack. Secondary care follow-up should be arranged after every hospital admission for asthma, and for patients who have attended the emergency department two or more times with an asthma attack in the previous 12 months.
A standard national asthma template should be developed to facilitate a structured, thorough asthma review. This should improve the documentation of reviews in medical records and form the basis of local audit of asthma care.
Electronic surveillance of prescribing in primary care should be introduced as a matter of urgency to alert clinicians to patients being prescribed excessive quantities of short-acting reliever inhalers, or too few preventer inhalers.
A national ongoing audit of asthma should be established which would help clinicians, commissioners and patient organisations work together to improve asthma care.

51. Key recommendations 2: Medical and Professional Care
All people with asthma -personal asthma action plan (PAAP)
Structured review by a healthcare professional with specialist training in asthma, at least annually
Factors that trigger or make asthma worse must be elicited routinely and documented in the medical records and personal asthma action plans (PAAPs)
Assess asthma control at every asthma review. Where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up
Aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues
All people with asthma should be provided with written guidance in the form of a personal asthma action plan (PAAP) which details their own triggers and current treatment, and specifies how to prevent relapse and when to seek help in an emergency.
People with asthma should have a structured review by a healthcare professional with specialist training in asthma, at least annually. People at high risk of severe asthma attacks should be more closely monitored, ensuring their personal asthma action plans (PAAPs) are reviewed and updated at each review.
Factors that trigger or make asthma worse must be elicited routinely and documented in the medical records and personal asthma action plans (PAAPs) of all people with asthma, so that measures can be taken to reduce their impact.
An assessment of recent asthma control should be undertaken at every asthma review. Where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up.
Health professionals must be aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues.

52. Key recommendations 3: Prescribing and medicines use
Patients prescribed > 12 SABAs in 12 mths - for urgent review of their asthma control
An assessment of inhaler technique - routinely undertaken and also checked by the pharmacist
Monitor non-adherence with preventers
Where long-acting beta agonist bronchodilators are prescribed for people with asthma - should be in a single combination inhaler
All asthma patients who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required.
An assessment of inhaler technique to ensure effectiveness should be routinely undertaken and formally documented at annual review, and also checked by the pharmacist when a new device is dispensed.
Non-adherence with preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored.
The use of combination inhalers should be encouraged. Where long-acting beta agonist bronchodilators are prescribed for people with asthma, they should be prescribed with an inhaled corticosteroid in a single combination inhaler.

53. Key recommendations 4: Patient factors and perception of risk
Patient self-management should be encouraged to reflect their known triggers (increase Rx before the start of the hay fever season, avoiding NSAIDs, early use of oral corticosteroids with viral or allergic-induced exacerbations)
Smoking and/or exposure to second-hand smoke -documented & offer referral
Parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, recognising when asthma is not controlled and knowing when and how to seek emergency advice
Efforts to minimise exposure to allergens and second-hand smoke should be emphasised especially in young people with asthma
Patient self-management should be encouraged to reflect their known triggers eg increasing medication before the start of the hay fever season, avoiding non-steroidal anti-inflammatory drugs or by the early use of oral corticosteroids with viral or allergic-induced exacerbations.
A history of smoking and/or exposure to second-hand smoke should be documented in the medical records of all people with asthma. Current smokers should be offered referral to a smoking-cessation service.
Parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, recognising when asthma is not controlled and knowing when and how to seek emergency advice.
Efforts to minimise exposure to allergens and second-hand smoke should be emphasised especially in young people with asthma.

54. NRAD New findings:
Chronic asthma with fixed airflow obstruction – new READ Code: H335.
Mean age of diagnosis 37 yrs (70% diagnosed > 15 yrs)
… and …

55. Asthma Deaths - Confidential Enquiries
Potentially preventable or avoidable factors contributing to death from asthma : identified nearly 50 years ago:
Failure to recognise risk status
Failure to recognise severity – 1979
Underuse of corticosteroids – 1963, 1975, 1979
Lack of Patient Education – 1963
Underuse of objective measures – 1963
Inadequate routine management and follow-up – 1979
Potentially preventable deaths – (77%) 1979
BMJ 1976;2:721; BMJ 1976;1:1493; BMJ 1980;280:687; BMJ 1982;285(6354):1570-1

56. Eastern Region Confidential Enquiry of Asthma Deaths
Supporting partners
Eastern Region Confidential Enquiry of Asthma Deaths

57. Acknowledgements Colleagues on the NRAD Core team
Rachael Andrews Programme coordinator
Hannah Evans Medical statistician
Jenny Gingles Northern Ireland
Debora Miller Northern Ireland
Rosie Houston Programme manager (until February2013)
Navin Puri Programme manager (from February 2013)
Laura Searle Program Administrator (until October 2013)
Strategic Advisory Group (Robert Winter) ; RCP Rhona Buckingham & Kevin Stewart (CEEU)
Steering Group (Derek Lowe) ; Expert Advisors ; Panel members ; Hospital co-ordinators ; HQIP (Jenny Mooney) ; Hannah Bristow (RCP Press Team)
Craig Bell (Scotland), Jenny Gingles (NI) and Karen Gully (Wales)
Writers group – Caia Francis, Shuaib Nasser, Jimmy Paton and Mike Thomas
Those who died from asthma & the clinicians who returned data