Boy, 15, collapsed and died during football game at school just days after doctors wrongly diagnosed him with asthma
A TEENAGE boy who collapsed and died during a football game at school was wrongly diagnosed with asthma just days before, an inquest heard.
Jake Lawler, 15, passed away after collapsing at Ashton on Mersey School in Sale, Trafford, on November 5 last year.
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The court heard a month before his death he attended Wythenshawe Hospital complaining of shortness of breath while playing football.
The inquest was told Jake, from Sale, had collapsed on the pitch on October 13, 2024.
Alison Mutch, senior coroner for Manchester South, has now written in a Prevention of Future Death report.
She warned how medical professionals incorrectly diagnosed the teenager with exercise induced asthma.
According to the report, an "abnormal ECG" and an "exercise induced syncope episode", were not recognised or followed up on.
Medical history provided by Jake's father was also "not assessed correctly".
The coroner concluded the abnormal ECG in combination with the teen's collapse "should have resulted in him being referred for an inpatient paediatric review and further testing".
And, when Jake was discharged, his ECG results were wrongly recorded as coming back "normal".
Jake's GP prescribed him medication for the misdiagnosed asthma, but it did not seem to have any effect on the youngster.
A test for asthma was also conducted five days after Jake collapsed.
But the nurse referred him back to a doctor as they did not think he suffered from the condition.
The 15-year-old tragically died from a biventricular arrhythmogenic cardiomyopathy just a month later.
The coroner wrote in her report: "It is probable that he would not have died on the day he did had the correct actions been taken.
"Jake's collapse was incorrectly attributed to his exercise induced asthma."
In her report, four areas of concern were highlighted to help prevent future deaths.
She stated Jake's ECG results were "key warning signs" that shouldn't have been missed, whether due to training or insufficient medical equipment.
Another "red flag event" laid out was "no clear national guidance" on the route to take after a paediatric exercise induced syncope.
The third point spotlighted covered asthma treatment prescribed by the GP, which failed to elevate Jake's symptoms, and the asthma assessment.
"Jake was assessed by his GP practice using the national asthma scoring system," wrote the coroner.
"However, the scoring system does not appear to facilitate scoring for exercise induced asthma.
"In Jake's case the readings and answers pointed to a well-controlled asthma.
"This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern.
"This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture."
The coroner added there was a "lack of curiosity" and a "lack of appreciation" regarding how limiting the assessment was.
"In my opinion action should be taken to prevent future deaths, and I believe you and/or your organisation have the power to take such action," she continued.
Manchester University NHS Foundation Trust and GP Surgery have until July 4 later this year to respond to the report.
Jake's school said at the time of his tragic death: "Our school community was absolutely devastated by the loss of one of our much loved and precious students, Jake Lawler, who recently passed away in tragic circumstances.
"As a school, we keep his family and friends in our thoughts and continue to support our students and staff during this incredibly difficult time.
"We would also like to take this opportunity to share a link to Jake's memorial fund, set up by his family to raise awareness of a very worthy cause - CRY (Cardiac Risk in the Young).
"The money will go towards raising awareness of young sudden cardiac death as well as supporting the families affected, supporting their screening programme and funding research and pathology."
What is biventricular arrhythmogenic cardiomyopathy
ACM is a condition where the cells in your heart muscle don't stick together properly.
The walls of your heart can become weak and blood may not be pumped as well as it should.
Your heart has four chambers. The top two are called the atria and the bottom two are called the ventricles. ACM can affect one or both of your ventricle chambers.
Jake suffered from biventricular arrhythmogenic cardiomyopathy, meaning it affected both.
ACM is usually a genetic condition which means if one of your parents have it, you have a 50/50 chance of inheriting the faulty gene that could cause ACM.
ACM symptoms
palpitations (a pounding or fluttering feeling in your chest or neck)
feeling lightheaded
fainting
feeling breathless or shortness of breath
abnormal heart rhythms (when your heart beats too fast, too slow or irregularly)
swollen ankles, legs or tummy area
feeling pain or discomfort in your chest.
How is ACM diagnosed?
Chest x-ray
Cardiac MRI scan
ECG (electrocardiogram)
Exercise test
Echocardiogram
How is ACM treated?
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