"Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented."

Let that sink in. https://twitter.com/PharminPractice/status/1358528017568567299
"Clinicians raised concerns in relation to the number of different guidelines relating to asthma. It was noted that it is not clear to healthcare professionals which guidelines should be used for the management of acute asthma attacks."
"The evidence revealed that further training is required for GPs and emergency departments in providing safe asthma care."
"The coroner said that her medical management on the multiple presentations over a short space of time appears to have centred largely on treating the immediate presentation as an isolated event."
"The Inquest, however, heard from a number of witnesses that there are concerns about the care provided to asthma patients nationally."
Last September we ran an event with @bigcatdoc. Mark's level of insight and involvement in @ginasthma guideline development is incredible. I recommend that you listen to his thoughts below.

https://pip.scot/2020/09/03/on-demand-dr-mark-levy-how-can-pharmacists-prevent-asthma-deaths/
"Reading that again I reflected on the urgency in my words. Time has passed but I still feel very strongly that community pharmacy must get organised and deliver a coherent set of services with the aim of preventing the deaths of people with asthma."

https://pip.scot/2020/12/11/pharmacistsinpharmacies-radical-idea-i-know/
We must never stop trying to improve this situation
You can follow @JohnathanLaird.
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