Finding into death of Min Guo

Contributing factors

• suboptimal use of asthma preventer medications
• absence of asthma management/action plan
• hay fever and seasonal asthma exacerbations not optimally managed
• high sensitisation to rye grass pollen
• lack of lung function testing and peak flow measurement
• exposure to outdoor elements during gust front passage
• unprecedented surge in demand for emergency services overwhelming ambulance response capacity
• delayed ambulance response due to system surge
• possible mould sensitisation as co-factor

Coroner's recommendations

1. Further research into the meteorological, biological and aerobiological factors that combine to create thunderstorm asthma events to improve prediction and forecasting
2. Verification and development of the thunderstorm asthma forecasting system to provide accurate and meaningful warnings
3. Continuation of public awareness campaigns and asthma action plans to improve community health literacy
4. Further medical, allied health and community education encouraging hay fever sufferers to undergo allergy testing to understand their susceptibility to thunderstorm asthma and inform clinical management
5. Public messaging when thunderstorm asthma warnings are issued to advise those at risk to remain indoors with windows and doors shut, turn off evaporative cooling or systems drawing outside air, and consider travelling to/from work later
6. Further development of capability for emergency services to provide estimated time of arrival information to callers to enable informed decision-making about alternative transportation during surge periods
7. Ongoing monitoring and evaluation of emergency services response capability and preparedness for future thunderstorm asthma events and other surge events of unknown cause