21-05-2025
Schoolboy, 15, died playing football after heart condition was wrongly diagnosed as asthma by medics with 'lack of curiosity', inquest hears
A 15-year-old schoolboy collapsed and died while playing football after wrongly being diagnosed with asthma by medics with a 'lack of curiosity' an inquest has heard.
'Loved' Jake Lawler, 15, was diagnosed with the common respiratory condition after he complained of 'breathlessness' to his GP, but he actually had a rare genetic heart condition.
Jake collapsed and died during a game at Ashton on Mersey School in Sale, Trafford, on November 5 last year.
In the weeks before his 'tragic' death, he was taken to hospital after he passed out during a sports game - but was discharged by medics who failed to recognise he had an abnormality in his heart.
Coroner Alison Mutch said the Jake's collapse was 'incorrectly attributed' to asthma rather than his heart condition and that if 'correct actions had been taken', he may not have died the following month.
Now, she has issued a warning to the Department of Health and Social Care, criticising the 'lack of curiosity' shown by medics who had reviewed Jake in the time preceding his death.
Ms Mutch, senior coroner for South Manchester, said the teen had been diagnosed by his GP with exercise-induced asthma and had been prescribed treatments which 'did not have any significant impact on his symptoms'.
An inquest into the teenager's death was told that on October 13 last year, he collapsed while playing football and experienced a 'short period of unconsciousness'.
Jake's father took him to Wythenshawe Hospital and an ECG - a test that records the electrical activity of the heart - was carried out.
The coroner said this showed an abnormality which was noted by the clinician but not recognised as a 'concerning finding'.
Further, it was heard that the medical history provided by Jake's father was 'not assessed correctly'.
The coroner said the abnormality on the ECG combined with his collapse should have resulted in him being referred for an inpatient paediatric review and for further testing.
'It is probable that he would not have died on the day he did had the correct actions been taken,' Ms Mutch said.
'Jake's collapse was incorrectly attributed to his exercise induced asthma.'
The inquest heard Jake was referred back to his GP for a review, which took place by telephone on October 14 and in person on October 18.
He was referred to the asthma nurse and a test was conducted on October 31.
But the nurse referred him back to the doctor and said 'they did not believe' the teenager had the respiratory condition.
There was a plan to refer him to paediatrics as it was 'clear' that the diagnosis of exercise-induced asthma being the cause of his collapse was 'unlikely' and the 'working diagnosis within the discharge summary was probably incorrect'.
The coroner said that the 'significance' of this was impacted by the fact the discharge summary had incorrectly described the ECG as 'normal'.
The inquest heard that after the fatal collapse attempts to resuscitate Jake were unsuccessful, and he died at Wythenshawe Hospital the following day.
The postmortem carried out found he had died as a consequence of having a rare heart disease known as 'biventricular arrhythmogenic cardiomyopathy'.
The genetic condition can cause weakened heart muscle.
Returning a narrative conclusion, Ms Mutch said the teen died as a result of the condition which was 'incorrectly diagnosed in life with exercise induced asthma'.
The coroner said his collapse and the abnormal ECG were 'not recognised or actioned appropriately'.
Ms Mutch identified several 'matters of concern' in relation to Jake's death.
In a prevention of future deaths report, she said: 'The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms.
'This was compounded by the exercise induced syncope [collapsing] being incorrectly linked to asthma.
'In addition, Jake was assessed by his GP practice using the national asthma scoring system.
'However, the scoring system does not appear to facilitate scoring for exercise induced asthma.'
She said that in Jake's case, his reading and answers in the scoring system pointed to him having 'a well-controlled asthma'.
The coroner continued: '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.
'A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed biventricular arrhythmogenic cardiomyopathy.'
The coroner also raised concerns over how ECG readings are often 'missed or misunderstood by clinicians which means that key warning signs are missed as in Jake's case'.
'Without an improvement there will be further avoidable deaths,' she continued.
'ECGs to rule out a possible cardiac issue cannot easily be given to children in a community setting.
'Jake presented with a clear paediatric exercise induced syncope.
'The inquest was told that there is no clear national guidance on the pathway to be followed in relation to such children although medical training emphasised that this should be treated as a red flag event.'
In a statement published on social media following the tragedy, Sale High School expressed support for students and staff.
'Our Sale High 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,' said the December 10 statement.
'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.'
The coroner issued the report to the Department of Health and Social Care, who have 56 days to respond.
