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It is almost 50 years since the first UK studies identified potentially preventable factors in the majority of asthma deaths.1 Those first reports led to the development of national asthma guidelines, intended to radically improve management. Since the 1980s, asthma care in the UK has shifted from secondary to primary care,2 linked to enhanced asthma nurse training and involvement. With the development of new doctor–patient partnerships in the form of personalised self-management plans and newer drugs with innovative delivery systems, improving asthma care in the future seemed a certainty. And yet, from 1992, the only ongoing inquiry into asthma death in the East of England fuelled background concern that preventable death was still a major issue.3 That concern was highlighted by the National Atlas of Variation in Healthcare for Respiratory Disease,4 published in September 2012, which showed great variation in almost every facet of asthma care delivery across the UK.
The National Review of Asthma Deaths (NRAD) was a confidential enquiry that investigated in detail 900 deaths of people of all ages who had died in 2012 with an ICD-10 code J459, where the underlying cause of death was classified as asthma. It was the first national study by the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians (RCP) to span both primary and secondary care, thus providing comprehensive information about asthma death. On World Asthma Day 2014, 24 years after the publication of the first UK guideline, the NRAD report, ‘Why asthma still kills’,5 stated asthma care was poor in most cases investigated and concluded that the vast majority of asthma deaths in the UK remain potentially preventable.
In all age groups, NRAD identified errors in primary and secondary care: in making the diagnosis of asthma; in the identification of risk factors (leading …