Ethan Hanson

30 Mar 2026 · Coroner Linda Lee · Warwickshire

The coroner's concerns

1. incomplete or incorrect recording of observations
“Absence of computerised mandatory-field safeguards”
2. misalignment with national guidance for paediatric abdominal pain
“Pathway design not fully aligned with national GIRFT guidance”
3. absence of practical mechanisms for neurodivergent assessment
“GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents”
4. lack of structured prompts for neurodivergent symptom expression
“Local processes provide no structured support for neurodivergent children or parents”
5. loss of critical GP observations and concerns
“Critical GP information not carried forward into the hospital assessment”