In April 2015, 13 year old Tamara Mills had a fatal asthma attack. When the coroner investigated how such a tragic event could have been allowed to happen, he found failings in the way her health records had been linked. In particular no one had flagged that, in the four years leading up to her death, she was seen by medical professionals 47 times in different parts of the NHS. Linking these records could have allowed her doctors to treat her differently and perhaps prevent her death.

What happened?

Over the last four years of her life, Tamara Mills’ health was deteriorating. However, because each time she saw a medical professional, this was treated as a unique incident, there was no overall appreciation of the trajectory which her condition was following.

After her death, the coroner identified a number of failings in Tamara Mills’ care. One of these was the lack of a coordinating record of the occasions on which she saw medical professionals. Without this overall picture, each case was treated as a unique incident.

Each medical professional who saw Tamara should have been able to access a comprehensive summary of her previous interactions with the NHS and make an informed decision about the care needed. In particular, there was a lack of communication between the hospital and out-of-hours services and her GP service.

If medical staff had access to a single record, they would probably have been able to see that Tamara’s overall health was getting worse. This would have allowed them to see the severity of the situation, review her medication and seek to control her symptoms. More comprehensive information and communication could have led to her being treated differently and she may not have died.

Where can I go for more information?

The Coroner’s Report into Tamara Mills’ death