Inquest into the death of a mother who died after an asthma attack
08/12/2004
Thank you to everyone involved in my case. I never dreamed of such an outcome and you have made such a long and difficult case seem easy and bearable.
Nigel, Derbyshire
Inquest into the death of a mother who died after an asthma attack
The Inquest into the death of a mother of three who died after a fatal asthma attack was concluded today at Coventry Coroner's Court.
Mr David Collins the Deputy Coroner for Coventry delivered his verdict this morning: "Tracey Bereza died at 14:20 on the 15th of April 2004 in Coventry and Warwick Hospital from oxygen starvation of the brain precipitated by acute severe asthma which on the 11th of April had become life threatening despite nebuliser treatment and possibly which might have been avoided by more immediate transfer to hospital following initial stabilisation of her condition. Her cause of death was cerebral hypoxia caused by a cardio-respiratory arrest caused by asthma (treated)."
41 year old, Tracey Bereza was a chronic asthmatic and became unwell on the evening of the 11th April 2004 and began to wheeze at home. Her breathing did not improve on using the nebulisers she had been prescribed by her doctor and her husband, Roger, called for an ambulance.
The ambulance crew took some time to arrive; Roger timed it as 35 to 40 minutes. Whilst Tracey was in the ambulance she suffered a cardio-respiratory arrest. She was resuscitated by the ambulance crew and taken to the Coventry and Warwick Hospital where her condition initially stabilised. She later deteriorated and suffered irreversible brain damage. Her life support was withdrawn on the 15th of April 2004.
The family believe that:
- There should have been an ambulance available about a mile away.
- The ambulance crew were trainees.
- The ambulance crew didn't attempt to stabilise Tracey's condition immediately in the bedroom at home before transferring her to the ambulance.
- The crew walked her down the stairs and she was in no fit state to walk. She was very short of breath and she was saying in the bedroom that her chest hurt.
- The crew failed to recognise the severity of Tracey's condition and that she was suffering a life threatening attack.
- The crew seemed to panic and lack confidence with Tracey's treatment.
The Coroner had the opportunity to examine expert evidence to conclude Tracey's cause of death. The treatment and care Tracey received from the ambulance crew was considered.
Tracey worked in the personnel department at a local school. She had previously been admitted to hospital on one other occasion a number of years ago with a severe asthma attack.
The family's solicitor Richard Follis, Partner at Alexander Harris said:
"Tracey Bereza's Inquest raises major issues about Coventry and Warwick ambulance service using probationary paramedics who are sent out alone without a more experienced and qualified person. There was a failure on behalf of the ambulance service to carry out an effective investigation into this case, the report failed to pick up numerous issues of concern."
"The evidence in this case revealed the disgraceful state of affairs that the ambulance service investigation tried to sweep under the carpet. Mrs Bereza died and other people are being put at risk by this wholly irresponsible approach."
"Tracey's family hope that her case will highlight how serious a condition asthma can be. Immediate action is paramount in such severe cases and delays to appropriate treatment for a patient can have grave consequences."
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