Finlay Roberts
20 Jun 2025 · Coroner Mary Hassell · Inner North London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of nursing observations
“lack of serial nursing observations was a fundamental omission from [the deceased]'s care”
2. lack of paediatric nursing observations
“lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of [the deceased]”
Linked reports
Closely relatedConfidence 0.92 · high
Earlier report
“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.”
This report
“The lack of serial nursing observations was a fundamental omission from [the deceased]'s care.”
Responses
2025-0316-Response-from-Royal-College-of-Emergency-Medicine.pdf ↗· Royal College of Emergency Medicine
Stated action
“RCEM is involved in the design and piloting of a revised paediatric early warning score specifically intended for Emergency Departments”
2025-0316-Response-from-Royal-College-of-Nursing-.pdf ↗· Royal College of Nursing
2025-0316-Response-from-Royal-College-of-Paediatrics-and-Child-Health.pdf ↗· Royal College of Paediatrics and Child Health
Stated action · 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.”
2025-0316-Response-from-Whittington-Health-NHS-Trust.pdf ↗· Whittington Health NHS Trust