Finlay Roberts

Coroner's concerns

AI summary

There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.

View full coroner's concerns

The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.

However, a 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 Billie Wicks.

I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.

2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.

Responses

4 respondents

Royal College of Emergency Medicine Education

15 Jul 2025 PDF

Noted

RCEM highlights existing standards requiring paediatric early warning scores, results from national audits, involvement in designing a revised paediatric early warning score, and advocacy for better staffing and resources. (AI summary)

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Dear Dr Hassell,

We are saddened to read of the death of Finlay Roberts from a condition which may have been treated if identified.

The standards that RCEM published in 2024 in our Guidelines for the provision of Emergency Services include that “Emergency Departments must use a specific paediatric early warning score and ensure that appropriate triggers and actions are in place.” All Paediatric early warning scores dictate how often observations should be checked depending on the age of the child and initial observations.

RCEM regularly conducts national audits of provision of care in children. In 2019 we looked at the assessment and management of febrile children and found that 97% of Emergency Departments were using a specific paediatric early warning score, which had improved since 2015.

RCEM is involved in the design and piloting of a revised paediatric early warning score specifically intended for Emergency Departments.

As a college we recognise that crowding and understaffing often have a role to play in poor care and continue to advocate for better staffing and resources. In conjunction with the Royal College of Nursing we have produced minimum standards of nursing for Emergency Departments, and recognise the issues in providing these.

We are also involved in the revision of the Facing for Future standards for paediatric care in Emergency Departments

With kind regards, Dr RCEM Quality in Emergency Care Committee Co-Chair

Royal College of Nursing Education

31 Jul 2025 PDF

Noted

The RCN states it is not the regulator for nurses and has no remit to address the concerns, but offers learning resources and highlights its work on the National Early Warning System (NEWS2) Observations Tracking Programme and collaboration with RCPCH on emergency care standards. (AI summary)

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Dear Mr Hassell,

Re: RCN Response to the Inquest touching the death of Finlay Joshua Roberts Regulation 28 - Prevention of Future Deaths Report.

Thank you for sharing your report with us regarding the tragic and untimely passing of Finlay Joshua Roberts. I was very sorry to hear of Finlay’s death. We respond to your Prevention of Future Deaths (PFD) Report dated 20 June 2024.

With a membership of over half a million registered nurses, midwives, health visitors, nursing students, nursing support workers, nursing associates and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world.

RCN members work in various hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on numerous issues by working closely with the Government, the UK parliaments and other national and worldwide political institutions, trade unions, professional bodies, and voluntary organisations.

Not all registered nurses, midwives, health visitors, nursing students, nursing support workers and nurse cadets are members of the RCN. The Nursing and Midwifery Council (NMC) is the independent regulator for nurses and midwives in the UK and nursing associates in England. The NMC’s register shows who can practise as a nurse or midwife in the UK or as a nursing associate in England.

We are not the regulator for nurses in the UK, nor do we have any control over individual nursing practice in individual workplaces; therefore, we have no remit to address the concerns you have noted in respect of this death. However, the RCN offers a suite of learning resources to support nurses, students, nursing support workers, midwives, and health care professionals at all stages of their careers. We provide expert-led, quality- assured, evidence-based education for continuing professional development CPD and learning on a range of topics and subjects.

Royal College of Nursing 20 Cavendish Square London W1G 0RN General Secretary & Chief Executive Telephone Email Executive Assistant: Telephone Email

It is not for the RCN to comment on the performance of any individual nurse or nursing associate. We note the Matters of Concern set out in Prevention of Future Deaths as:

1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.

We have considered your report carefully. Of the matters noted, we believe one is of particular note to the Royal College of Nursing.

1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.

From the information provided we do not know how many observations (if any) Finaly had during his stay in the Emergency Department. Observations are important as part of a holistic assessment of children. There are many reasons why observations might not be obtainable, however the RCN recognises that challenges are significantly exacerbated by gaps in clinical nursing rotas resulting in understaffed departments. The RCN cannot comment on the specific factors in this emergency department that may have contributed to Finlay’s tragic passing.

Beyond calls and actions at the individual level, such as awareness, education and training, broader systemic and cultural considerations are necessary. Staffing levels, skill mix within the team, clinical governance, policy, procedures, escalation plans, raising concerns, management of deteriorating patients, patient safety reviews, and how organisational learning is undertaken following mortality and morbidity reviews must not be overlooked.

The RCN has been collaborating with NHS England and the Royal College of Paediatric and Child Health (RCPCH) to develop a single national paediatric early warning system (PEWS) for England since 2018 and are supportive of equivalent processes across the UK. The RCN has produced supportive educational material to support the role out of this initiative System wide Paediatric Observations Tracking Programme. This work is aimed for implementation across the four-nations in the UK.

The RCN is also collaborating with the RCPCH in the revision of the emergency care standards for children and young people which will specify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations.

According to the NMC annual report, 27,168 people left the register in the last year, slightly fewer than the previous year. Of those who left, 20.3% (5,508) were nursing and midwifery professionals who left within the first 10 years of starting their careers. This percentage has increased for the third consecutive year, up from 18.8% in 2020-2021. Additionally, 49% of those who completed the leavers survey indicated leaving their profession earlier than expected. Nursing staffing levels impact patient safety. We can’t improve one without improving the other. Our Nursing Workforce Standards are a roadmap for designing a workforce that can offer patients high-quality care.

Many nurses are caring for unsafe numbers of patients and facing overwhelming pressure and burnout. A 2024 report by the University of Bath identifies psychological stress, workload, staff shortages, and pay as the top reasons for staff leaving the NHS. Rising burnout symptoms, declining job satisfaction, and low confidence in improving working conditions were also observed. Additionally, the proportion of NHS nurses recommending working for the NHS to others has significantly decreased, highlighting significant retention concerns.  The right nursing staff with the right skills must be in the right place at the right time to deliver the care children and young people require.

Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Finlay’s family.

Whittington Health NHS Trust NHS / Health Body

15 Aug 2025 PDF

Action Taken

The Trust has implemented training and induction enhancements, updated the Emergency Department Nurse in Charge checklist, mandated completion of an ED Paediatric Discharge Checklist, and is undertaking ongoing monitoring and training to improve standards of practice. (AI summary)

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Dear Senior Coroner Hassell, Thank you for your Prevention of Future Deaths (PFD) report dated 20 June 2025 concerning the tragic death of Finlay Joshua Roberts. First and foremost, we extend our deepest condolences to Finlay’s family. We fully recognise the seriousness of the matters you have raised and are committed to sustained, systemic improvements to ensure that lessons are learned and embedded into our practice. Below is our response to the concerns raised, along with the actions taken and those in progress to reduce the risk of similar future incidents.

1. Failure to Carry Out Serial Nursing Observations We accept the coroner's finding that there was an omission in not conducting serial complete sets of nursing observations. Since Finlay’s death, a number of interventions have been implemented. Actions Taken:
• Training & Induction Enhancements: o All new nurses now receive training on vital signs monitoring and escalation during induction and in-house triage training. This ensures that all new starters have a foundational understanding of the importance of recording and escalating abnormal observations from the outset. All clinical staff are also required to familiarise themselves with the department’s common presentation policies during their induction. Dr

Chief Medical Officer Medical Directorate Whittington Health Jenner Building Magdala Avenue London N19 5NF

Tel: Email:

Whittington Health NHS Trust

Chair: Chief Executive:

Helping local people live longer healthier lives o All adult nurses deployed to work in Paediatric Emergency Department are provided with local induction to the unit as set out in the Trusts induction policy. o In addition, practice development support has been introduced in Paediatric Emergency Department, with a focused priority on vital signs monitoring and escalation training for the entire Emergency Department team to ensure that they have the same foundation. o At triage a complete set of vital signs appropriate to their clinical presentation is required for every child presenting to the department with a medical complaint. This standard has been reinforced through the Emergency Department Triage Training Study Day, which all triage nurses attend. These triage observations will be as recommended by the Royal College of Emergency Medicine (RCEM)
• Monthly and Manual Audits: o Monthly audits of compliance with vital sign observations have been instituted with the support of the Information Requests Team, with outcomes reviewed by the paediatric emergency department senior team. These will be used to identify ongoing training needs and support continuous improvement with feedback to the team. o Senior nurses perform random manual audits of observation charts four times per month. The data is feedback to the team through email, message of the month and on an individual basis. o The vital signs observations audits will be presented at the division’s quality meeting on a quarterly basis. The next Meeting is scheduled August 2025.

• Simulation Training with PEWS: o Paediatric Early Warning Scores (PEWS) have been embedded into multidisciplinary simulation training. These simulations take place on alternative Thursdays, including the children’s and young people department which allows collaborative learning for acute Paediatrics.
• Clinical Standards Embedded: o A complete set of vital signs appropriate to the clinical presentation is explicitly required at triage for all children presenting with medical complaints, and those with abnormal observations will be escalated according to the score requirement in national guidance as stipulated by the national paediatric early warning score (PEWS).

Whittington Health NHS Trust

Chair: Chief Executive:

Helping local people live longer healthier lives o The timing of a repeat set of observations follows the PEWS algorithm which supports escalation level including a communication and response framework. o This requirement is reinforced in training days attended by all nurses involved in triage, handover briefings, and via monthly staff communications. o Local records are held on staff training/, competences, (PEWS, triage)

• Electronic Monitoring Enhancements: o Four additional electronic devices have been deployed in the department to facilitate real-time recording and review of vital signs. Each Nursing staff member has access to an electronic device for inputting Vital signs. o The Nurse in Charge (NIC) workstation has been upgraded to a dual-screen system, enabling more effective live monitoring of deteriorating patients. o The digital medical record in PED has been updated and all current staff who use it have been notified. proforma used for assessment

2. Medical Staff Not Recognising the Lack of Observations We acknowledge that staff failed to identify that vital observations were incomplete and not repeated at the time of Finlay’s discharge. In response: o The emergency Paediatric Clerking proforma now requires doctors to specify the frequency that observations should be done. o The ED paediatric discharge checklist now requires that there is a review of patient’s vital signs prior to discharge. This has been implemented since Finlay’s death and its use will be audited regularly. o The discharge checklist will be disseminated at ED and surgical induction in August and paediatric induction in September and at all future medical inductions thereafter. o Audits will be conducted and will be presented at the division’s quality meeting on a quarterly basis.

Whittington Health NHS Trust

Chair: Chief Executive:

Helping local people live longer healthier lives
3. Systemic Concerns Around Observation Practice You raised concerns that the issue of missed observations may not be confined to Whittington Health NHS Trust. Actions Taken and Ongoing:
• Collaboration and Benchmarking: o We are actively participating in a regional benchmarking initiative led by the North Thames Paediatric Network to examine standards of practice, share learning, and identify system-wide improvement opportunities.
• Environmental and Staffing Enhancements: o The Paediatric Emergency Department currently has two recent vacancies. The department maintained 100% filled vacancies prior to this. o The lead Nurse for PED has focused on retention and recruitment to ensure nursing vacancies are mitigated with support from general ED nurses who have completed the Paediatric ED rotation and RCEM Paediatric competencies. o Staffing levels in the Paediatric Emergency department have been reviewed and aligned with SNCT (safer nursing care tool data), and professional judgement based on staff feedback. This review resulted in additional nursing staff. The staffing levels will continue to be reviewed and reported to the Board on a six monthly basis. o We have introduced the allocation of cubicles where nurses are assigned responsibility for specific cubicles and key assessments i.e. Triage and patient cohorts to ensure ownership and continuity of care. o Triage responsibilities have been restricted to nurses with a minimum of one year of paediatric emergency experience and completion of the RCEM triage competency workbook. All triage nurses undergo Manchester Triage training and competency training before they can autonomously assess children on arrival.
• Safe Staffing Governance: o The Emergency Department Nurse in Charge checklist has been updated to align with RCEM guidance on paediatric emergency staffing and now explicitly includes paediatric-specific checks.

4. Timetable for Outstanding and Continuing Actions

Whittington Health NHS Trust

Chair: Chief Executive:

Helping local people live longer healthier lives There are no outstanding actions. However, for continuing actions there will be: o Ongoing monitoring of compliance by the senior nursing and medical team with oversight from the paediatric and emergency department clinical governance committees reporting into the Patient Safety Group on a 3 monthly basis. Patient Safety Group reports to Trust Board via the Quality Governance and Quality Assurance Committees. o Ongoing training and induction for all staff in regard to the importance of complete observations and their escalation. This training will also be part of all simulation training in PED o Continued use of the ED paediatric discharge checklist. o There will also be ongoing participation in the regional benchmarking initiative led by the North Thames Paediatric Network to examine standards of practice, share learning, and identify system-wide improvement opportunities. o Continued monitoring of staffing levels and equipment to ensure safety is maintained

Conclusion We remain deeply saddened by Finlay’s death and are committed to ensuring this loss leads to lasting change. We are grateful for your findings and for the opportunity to implement and share learning that may help prevent similar deaths in future. Please let us know if any further information is required or if clarification of any part of this response would be helpful.

Royal College of Paediatrics and Child Health Education

18 Aug 2025 PDF

Action Planned

The RCPCH is in the process of updating its Facing the Future Standards for Emergency Care, to be published later in 2025, which will clarify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations. (AI summary)

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Dear Mr. Hassell,

Re: RCPCH Response to the Inquest Touching the Death of Finlay Joshua Roberts A Regulation 28 Report – Action to Prevent Future Deaths

Thank you for sharing your report with us regarding the tragic and untimely passing of Finlay Joshua Roberts. I was very sorry to hear of Finlay’s death.

We have considered your report carefully and note your concerns regarding a lack of nursing observations. You have also noted that a lack of paediatric nursing observations was the subject of another of your recent PFD reports following the death of Billie Wicks, to which RCPCH provided a comprehensive response in May 2025.

As we noted then, observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtained, and RCPCH recognises that challenges in adequately staffing emergency departments may be one reason. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact on paediatric staffing, and we continue to advocate at a local and national level for an active reduction in these gaps.

The RCPCH Facing the Future Standards for Emergency Care ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of audit, review and revision and update of these standards, to be published later in 2025. The revised version will set out that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations. This update has been led by an Intercollegiate Committee for Emergency Care, including representation from the Royal College of Nursing.

Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Finlay’s family.

Report sections

Investigation and inquest

On 19 July 2024, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Finlay Roberts aged 2 years and 11 months. The investigation concluded at the end of the inquest on 9 June 2025.

I made a determination at inquest that Finlay died from a rare (in a child) but recognised natural cause, a sigmoid volvulus.

Circumstances of the death

Finlay’s parents took him to the Whittington Hospital the night before he died, but the paediatric emergency department was understaffed and it was an extremely busy night.

There was a failure to conduct serial nursing observations; not all tests were carried out as appropriate; and, though specialist advice was sought from Great Ormond Street Hospital, the late arrival of x-rays, a lack of complete information and a failure to close the loop of communication meant that the advice was not obtained before Finlay was discharged home.

It is unclear whether different hospital care that night would have saved Finlay’s life. It would have given him a chance.

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