Viviana-Ray Butnaru
4 Mar 2026 · Coroner Jyoti Gill · Essex
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of guidelines for identifying heart related issues in A&E paediatric environment
“There appears to be a lack of local or national guidelines assisting those assessing patients in an accident and emergency and paediatric environment to assess the correct pathway for identifying and investigating those who may present with heart related issues such as myocarditis”
2. lack of awareness of Parvovirus surge in children
“Raising awareness of the existence of Parvovirus considering the surge of this virus in children post the Covid 19 pandemic”
3. delayed official reporting of cardiomegaly on chest X ray
“Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later”
4. incomplete exploration of metabolic acidosis causes
“Underlying causes for metabolic acidosis were not fully explored”
5. incomplete documentation of observations and handovers
“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”
Linked reports
Closely relatedConfidence 0.87 · 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”
This report
“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.”