The coroner also said Jessica's lung capacity was not estimated. "The explanations given to Jessica-Lee and her mother, concerning diagnosis and treatment, were inadequate, and there was no clear plan devised to monitor the progress of Jessica-Lee's asthma. I find that his deficiencies may also have been exacerbated by his slightly compromised English skills," she added.
Dr Jeyaprakash had failed to apply proper principles in treating asthma, Ms Sheppard said. A specialist respiratory physician who was asked to review the case said Jessica could have been saved.
"Overall, I find that Dr Jeyaprakash's management of Jessica-Lee was of a relatively cursory nature, possibly reflective of the pressure of work and the large number of patients he was required to manage," Ms Sheppard said.