Delayed or missing clinical observations in pediatric emergency care
Royal College of Paediatrics and Child Health received 3 coroners' reports about this hazard between 16 Aug 2024 and 4 Mar 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.”
Original on judiciary.uk ↗ Royal College of Paediatrics and Child Health responded, stating 5 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“I intend to make a prevention of future deaths report”
“We will continue to be strongly supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.”
3 more stated actions in the Promises tab.
- 10 months laterClosely relatedConfidence 0.92 · high
“The lack of serial nursing observations was a fundamental omission from [the deceased]'s care.”
Original on judiciary.uk ↗ Repeated from the earlier report:nursingobservationsdeceased's
Royal College of Paediatrics and Child Health responded, stating 1 specific action.Response (PDF) ↗
“We are currently in the process of audit, review and revision and update of these standards, to be published later in 2025.”
Stated timescale: later in 2025
- 8 months laterClosely relatedConfidence 0.87 · higha different coroner
“Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded.”
Original on judiciary.uk ↗ Repeated from the earlier report:nursingstaffobservations
Royal College of Paediatrics and Child Health responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Royal College of Paediatrics and Child Health
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2024 → 2025Finlay Roberts10 months after Daniel Klosi · same coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight that failing to obtain or record nursing observations in pediatric emergency care can lead to serious harm. They share the concern that absent observations should be treated as abnormal and escalated promptly.
Daniel Klosi · 16 Aug 2024
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.”
Original on judiciary.uk ↗ Finlay Roberts · 20 Jun 2025
“The lack of serial nursing observations was a fundamental omission from [the deceased]'s care.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust has ratified and disseminated an updated guideline for recording and escalating physiological observations in children and young people. This includes guidance for staff that the inability to obtain observations should be considered and escalated in the same way as abnormal observations.”
2024 → 2026Viviana-Ray Butnaru1 year 7 months after Daniel Klosi · different coronerClosely relatedConfidence 0.87 · high
Closely relatedConfidence 0.87 · highBoth reports highlight problems with ensuring that children's clinical observations are properly obtained, recorded, and acted upon when staff cannot complete them.
Daniel Klosi · 16 Aug 2024
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours”
Original on judiciary.uk ↗ Viviana-Ray Butnaru · 4 Mar 2026
“Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust has ratified and disseminated an updated guideline for recording and escalating physiological observations in children and young people. This includes guidance for staff that the inability to obtain observations should be considered and escalated in the same way as abnormal observations.”
Stated action
“I intend to make a prevention of future deaths report”
Stated action
“We will continue to be strongly supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.”
Stated action · timescale: 2025
“We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK”
Stated action
“Emergency clinicians with responsibility for the care of children receive training in how to assess risk and immediately manage children's mental health needs and support their family/carers”
Stated action
“The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness”
Stated action · timescale: later in 2025
“We are currently in the process of audit, review and revision and update of these standards, to be published later in 2025.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Royal College of Paediatrics and Child Health at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2025 | 0.79 | 0.11 | Closely related · 0.92 | same |
| 2024 → 2026 | 0.71 | 0.07 | Closely related · 0.87 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Royal College of Paediatrics and Child Health
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.