Finding into death of Clarence Tuivaiese Nicholas Leo

Contributing factors

• Suboptimal preventer medication use
• Non-compliance with prescribed asthma medications
• Severe obstructive sleep apnea with profound oxygen desaturation
• Morbid obesity
• High sensitisation to rye grass pollen
• Sensitisation to Alternaria mould
• Ran out of reliever medication (Salbutamol)
• Unpredicted surge in emergency service demand
• Delayed ambulance response during unprecedented event
• Lack of lung function testing

Coroner's recommendations

1. Further research into meteorological, biological and aerobiological factors contributing to thunderstorm asthma events to improve prediction and forecasting
2. Verification and development of the thunderstorm asthma forecasting system to provide accurate public warnings
3. Continuation of public awareness campaigns linking hay fever to thunderstorm asthma and escalating preventative therapy
4. Medical, allied health and community education encouraging hay fever sufferers to undergo allergy testing and develop specific management plans
5. Public guidance that when thunderstorm asthma warnings are issued, at-risk individuals remain indoors with windows and doors shut, turn off evaporative cooling systems, and consider travelling later
6. Development of systems to provide callers with specific estimated ambulance arrival times to enable informed decision-making during surge events
7. Continued improvement and testing of surge scripts and exit scripts in emergency communications
8. Further research on Alternaria mould as a potential co-factor in thunderstorm asthma
9. Evaluation of effectiveness of community preparedness and prevention strategies