Source · Prevention of Future Deaths

Ethan Hanson

Ref: 2026-0229 Coroner: Linda Lee Area: WarwickshireThis report is being sent to: NHS England, George Eliot Hospital NHS Trust | College of General Practitioners 4 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted the absence of electronic safeguards for observation recording and a paediatric pathway not aligned with national guidance. Concerns included insufficient mechanisms for assessing neurodivergent patients and parents, and critical GP information not transferring effectively to the hospital.

56-day deadline 25 May 2026 stated in the report

Responses identified 4 of 2

Coroner's concerns

AI summary

The coroner noted the absence of electronic safeguards for observation recording and a paediatric pathway not aligned with national guidance. Concerns included insufficient mechanisms for assessing neurodivergent patients and parents, and critical GP information not transferring effectively to the hospital.

View full coroner's concerns

Absence of computerised mandatory–field safeguards There is no electronic system with mandatory fields or hard-stops to prevent incorrect or incomplete recording of observations or pain scores. A transposition error between oxygen saturation and temperature occurred. The absence of automated safeguards requiring complete and accurate observations before pathway selection or discharge creates a risk that clinically significant information may be overlooked. Although there is an intention to develop such a system, it is not currently in place.

Pathway design not fully aligned with national GIRFT guidance The Trust is developing a triage model for paediatric abdominal pain. Evidence heard at inquest showed that the pathway options do not mirror the structure or escalation principles contained in the national GIRFT guidance for paediatric abdominal pain and appendicitis. This carries a risk that children with time-critical surgical conditions may not be escalated promptly or placed on an appropriate pathway.

GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.

Local processes provide no structured support for neurodivergent children or parents Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted.

Critical GP information not carried forward into the hospital assessment The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer.

Responses

4 respondents

Old Mill Surgery GP

Indexed date: 14 Apr 2026 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The surgery implemented a new protocol within its EMIS clinical system. • The protocol prompts clinicians to confirm appropriate referral pathways, notify receiving teams, complete necessary referral documentation, and arrange ambulance transfer where clinically appropriate. • The protocol is now available to all clinicians, including locum doctors and GP registrars, and forms part of their induction.

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Old Mill Surgery, Marlborough Road, Nuneaton, Warwickshire, CV11 5PQ 14th April 2026 FAO Linda Lee Acting Area Coroner for Coventry & Warwickshire Private & Confidential Investigation into the death of Ethan Michael Hanson who died on 26th April 2025 Subject: Response to Inquest Report – Actions Taken Thank you for your inquest report. I can confirm that an ambulance was in the process of being arranged to transfer Ethan to hospital. However, due to the anticipated delay, Ethan’s mother chose to take him to George Eliot Hospital, as it is located approximately four minutes from the Practice. Her decision was made to avoid any further delay in his assessment within the Emergency Department. At the time of the incident, the Practice was not aware of the specific paediatric referral pathways at the hospital, as this information had not been formally communicated to us. Following this event, we have implemented a new protocol within our EMIS clinical system and also laminated the protocol and displayed in all clinical rooms. This protocol prompts all clinicians, at the point of referral, to:  Confirm the appropriate referral pathway  Select the correct hospital for paediatric services  Access and use relevant contact numbers to notify the receiving team in advance  Complete the necessary referral documentation to accompany the patient  Arrange ambulance transfer where clinically appropriate This protocol is now available to all clinicians, including locum doctors and GP registrars in training and forms part of their induction, with the aim of strengthening our referral processes and reducing the risk of similar incidents occurring in the future.

George Eliot Hospital NHS Trust

NHS Trust

Letter dated 21 May 2026 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust implemented immediate mitigating actions for paediatric observations, including requiring repeat observations prior to discharge and reviewing 'yellow' triage patients with a Registrar or Consultant. • Access to the Integrated Care Record System was granted to all Emergency Department and Clinical Assessment Unit staff to enable review of GP records. • A formal escalation pathway and supporting materials for managing neurodivergent patients were developed and approved, with implementation commencing.

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Dear Ms Lee

RE: REGULATION 28 REPORT – ETHAN HANSON

Further to your report which the Trust received on the 30 March 2026, in accordance with paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009 and the regulations 28 and 29 of the Coroner’s (investigations) Regulations 2013, I offer the following response:-

Following the Coroner’s inquest on Monday 16 April 2026, regarding the death of Ethan Hanson (EH). The Trust would like to formally acknowledge the findings of the coroner and recognises its responsibilities in conjunction with the actions as detailed in the Regulation 28, Prevention of Future Deaths notice.

In response to the Regulation 28 notice, the Trust took immediate action by convening a multidisciplinary meeting on Wednesday 29 April 2026. The meeting was chaired by the Chief Nursing Officer and attended by both internal and external partners, including representation from General Practitioners and the Integrated Care Board (ICB).

The purpose of the meeting was to undertake a collective, multidisciplinary review to understand how future care delivery could be strengthened. The discussion focused on ensuring that all opportunities are consistently identified and acted upon, with the aim of developing a more robust and integrated care pathway that mitigates the risk of similar incidents occurring in the future.

The actions and outcomes of the meeting form part of the Trust’s response below.

1. Absence Of Computerised Mandatory Field Safeguards There is no electronic system with mandatory fields or hard‑stops to prevent incorrect or incomplete recording of observations or pain scores. A transposition error between oxygen saturation and temperature occurred. The absence of automated safeguards requiring complete and accurate observations before pathway selection or discharge creates a risk that clinically significant information may be overlooked. Although there is an intention to develop such a system, it is not currently in place.

Trusts Response

The Trust recognises the concerns raised regarding the absence of an electronic observation system incorporating mandatory fields and automated safeguards to prevent incomplete or inaccurate documentation. The identified transposition error between oxygen saturation and temperature illustrates the inherent risks associated with reliance on manual processes and underscores the need to strengthen digital controls to better support clinical decision-making and patient safety.

An immediate mitigating action was implemented shortly after Ethan’s death to reduce the risk of transcription errors while observations remain paper-based. This requires all paediatric observations to be repeated prior to discharge from the department, with compliance monitored through routine audit processes.

In addition, all children triaged as ‘yellow’ or above under the Manchester Triage System are reviewed with a Registrar or Consultant. The ‘yellow’ category denotes patients with significant conditions that are not immediately life-threatening but have the potential to deteriorate; as such, the target is for these patients to be clinically assessed within 60 minutes

In terms of the future electronic system, the Chief Digital Officer has offered the following response:

The Trust is currently in the implementation phase of its Electronic Patient Record (EPR) programme. As part of this work, the Trust is reviewing the critical delivery timeline to reflect issues identified within the programme to date and is therefore unable to confirm a specific go-live date at this stage, although implementation is currently anticipated in August 2027. The programme is well underway, with funding clearly identified within the Trust’s financial plans, and the Trust remains fully committed to successful delivery across both George Eliot Hospital NHS Trust and South Warwickshire University NHS Foundation Trust.

The Trust recognises that the implementation of the new EPR system presents a significant opportunity to improve the reliability and safety of clinical documentation and workflow processes. Although the detailed system design remains under development, the intention is that the EPR will include enhanced validation processes, structured documentation, and clinical safety functionality to reduce the risk of incomplete or incorrect observations being recorded or overlooked. This includes

consideration of mechanisms such as mandatory fields, automated prompts, escalation triggers, and decision-support safeguards to support clinicians prior to pathway selection or discharge decisions. We can confirm that the new EPR system will flag any critical or unusual observations and will not allow transcriptions of observations that could not be possible such as oxygen saturations of 140. Until the EPR system is fully implemented, the Trust will continue to reinforce existing governance arrangements, staff training, and clinical oversight processes to minimise the risk of similar errors occurring and to ensure that observations and clinical assessments are reviewed appropriately as part of safe patient care. Additionally, the Trust will seek to implement PEWS documentation within the current electronic Patient Track for use in the Children’s Assessment Unit (CAU) as an interim measure to strengthen the recording, visibility, and escalation of paediatric observations

2. Pathway Design Not Fully Aligned With National GIRFT Guidance The Trust is developing a triage model for paediatric abdominal pain. Evidence heard at inquest showed that the pathway options do not mirror the structure or escalation principles contained in the national GIRFT guidance for paediatric abdominal pain and appendicitis. This carries a risk that children with time‑critical surgical conditions may not be escalated promptly or placed on an appropriate pathway.

Trust Response

The Trust recognises that the current triage model for paediatric abdominal pain does not fully align with national GIRFT guidance, creating a potential risk to timely escalation of children with serious surgical conditions. In response, immediate actions have been taken to embed the GIRFT pathway into practice, alongside targeted education, simulation training, and a formal review to update the Trust’s Standard Operating Procedure and ensure full compliance. These actions include:
• The Trust is ensuring that all staff are following the GIRFT Paediatric Acute Abdominal Pain & Appendicectomy Best Practice Pathway Guidance (June
2022).
• The pathway has been shared with all the clinical staff within the Emergency and Paediatric Department to ensure all staff are aware of the expected approach and to support a more consistent practice.
• The Paediatric Lead delivered a teaching session on the 13 March 2026 to the Paediatric Team focusing on acute abdominal pain, using this case to highlight key learning points. The importance of following the pathway was reinforced again in the clinical huddle afterwards. This teaching session is being repeated on the 22 May 2026.
• The learning from this case is being built into a simulation programme. The upcoming CAU simulation sessions will involve a wider multi-disciplinary group and will include scenarios around abdominal pain, including neurodivergent children, to support better recognition, communication, and escalation. These sessions are held monthly.
• The GIRFT guidance (paediatric acute abdominal pain) along with the current Trust process, is going to be reviewed to identify any gaps and actions needed

to ensure compliance and then a new Standard Operating Procedure (SOP) will be compiled to align with GIRFT. This will be completed by the end of June 2026.

3. GIRFT Guidance Lacks Practical Mechanisms For Assessing Neurodivergent Children And Parents The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history‑taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance Trusts Response The Trust acknowledges the concerns raised regarding the absence of practical mechanisms within the GIRFT guidance to support assessment and communication with neurodivergent children and their families. However, this matter falls outside the Trust’s direct remit. GIRFT has been made aware of these considerations through receipt of the Coroner’s Regulation 28 Report to Prevent Future Deaths. The Trust will, however, ensure full compliance with any enhanced or updated guidance issued by GIRFT in response to these findings.

4. Local Processes Provide No Structured Support for Neurodivergent Children Or Parents Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted. Trusts Response The Trust recognises the risk that the absence of structured prompts within local assessment processes may lead to challenges in identifying how neurodivergence can influence symptom presentation and communication. In response, the paediatric team at GEH has undertaken a review of current processes, guidelines, and training, with actions in place to strengthen support for children with neurodiverse conditions and learning difficulties, ensuring care is delivered in line with best practice and supports improved clinical outcomes Actions taken:
• The paediatric casualty card is currently being amended to include whether the parent/carer has any potential neurodiverse implications which may affect communication. This has been discussed with the Paediatric Neurodiversity & Learning Disability Lead for South Warwickshire NHS University Foundation Trust (SWFT), and it was identified that the question to be placed on the casualty card should be “does this child have any communication, sensory or

behavioural needs”. Work is now being undertaken to have this included on the casualty card and will be completed by the end of May 2026.
• Compliance with the Oliver McGowan Mandatory Training is required for all staff. Current compliance within the Clinical Assessment Unit (CAU) stands at 81%, with full compliance expected by the end of June 2026.
• A formal escalation pathway has been developed to support staff in managing neurodivergent patients, promoting increased clinical curiosity and consideration of atypical presentations. Supporting materials, including a flowchart and handbook were approved on 21 May 2026 and implementation will commence.
• Accessible, easy-to-understand patient and family information leaflets are being developed to support families in recognising and escalating concerns. These materials will be co-produced with Young Inspectors, established through partnership with IMPACT (Warwickshire County Council’s Young People’s Forum for SEND), Healthwatch Warwickshire, and Warwick Hospital, and will be shared across GEH and SWFT.
• The Trust has a Play Specialist in post, providing specialist support to reduce anxiety and enhance communication for neurodivergent children through appropriate tools and techniques.
• The Trust supports the safe prioritisation and expedited flow of neurodivergent children through the Emergency Department and Clinical Assessment Unit, where clinically appropriate
• The Trust is undertaking an evaluation of a pager system to enable families to temporarily leave the department while awaiting assessment where the Clinical Assessment Unit (CAU) environment may be causing distress. A formal demonstration of the system is scheduled for 21 May 2026 to inform feasibility and next steps.
• The FLACC (Face, Legs, Activity, Cry, Consolability) behavioural pain assessment tool is being implemented within CAU to support more consistent and appropriate pain assessment, with full implementation anticipated by the end of June 2026.
• The Trust’s Communications Team is developing a formal communications plan, in partnership with the Paediatric Neurodiversity & Learning Disability Lead, to increase awareness and utilisation of Hospital Passports and “All About Me” tools. This will include a public-facing campaign, commencing in July 2026 and continuing thereafter.
• A neurodivergent champion role is being established across GEH and SWFT, supported by a dedicated training programme. These roles will act as advocates for neurodivergent patients and their families, with implementation scheduled from July 2026.
• The professional development portfolios for Advanced Care Practitioners are being reviewed and updated to incorporate competencies relating to the care of neurodivergent patients, with completion expected by October 2026.
• The Trust is scoping the development of a dedicated desensitisation environment within the Emergency Department. As part of this work, the Operational and Emergency Department Managers are undertaking a visit to St George’s Hospital, Stafford, to review a Cubbie Sensory Pod—an evidence-

based sensory environment designed to reduce anxiety and sensory overload. This will inform future planning to enhance the assessment environment and support improved communication for neurodivergent patients and families
• The Trust acknowledges the need for a digital solution to flagging neurodivergence. Our approach within our new EPR system is still under final discussion, however our overall intention is to apply a reasonable adjustments flag to the child’s digital record with the consent of the parent, with documentation focused on the need for tailored communication support with parents, rather than recording any parental diagnosis itself. This would align better with data minimisation principles while still addressing and fulfilling the required clinical and safety intent.

5. Critical GP Information Not Carried Forward Into The Hospital Assessment The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer.

Trust Response The Trust, alongside GP and ICB representatives, acknowledged that the absence of access to GP patient records represented a significant gap in the care provided to EH.

Following a multidisciplinary meeting held on 29 April 2026, it was agreed that all nursing and medical staff within the Emergency Department and Clinical Assessment Unit would be granted access to the Integrated Care Record System. This enables clinicians to review GP records, including the referring clinician’s working diagnosis and clinical considerations, prior to hospital assessment.

All parties recognised the critical importance of timely access to comprehensive patient information, and this action was endorsed as a key improvement to support safer, more informed clinical decision-making. The system is now fully operational and accessible to all Emergency Department staff

The Trust is undertaking a review of the Directory of Services with system partners to ensure an awareness of services delivered across all local hospitals for both adults and paediatrics. It is envisaged that this will be completed by the end of July 2026.

Actions taken:
• The Trust will undertake an evaluation of an electronic interface with the Directory of Services for General Practice, with the aim of ensuring that the most current and accurate information is consistently accessible to all GPs. This work is scheduled for completion by the end of July 2026.
• The Trust is developing a coordinated communications programme to clearly articulate the range of services provided across GEH and SWFT. This will be

disseminated through multiple channels, including the Trust websites, NHS 111, West Midlands Ambulance Service (WMAS), and primary care, to support informed referral decisions and promote service awareness.
• The Trust intranet is currently undergoing review and update to ensure accuracy and accessibility of information. In parallel, the Directory of Services for NHS 111 and WMAS has been reviewed and is confirmed to be current and up to date.

6. General Learning

Learning from this case has been shared with the whole multidisciplinary team in GEH emergency department and beyond. Further multi-disciplinary team simulation sessions (completed monthly), led by the Paediatric Practice Educator, will involve a presentation of a neurodivergent patient with abdominal pain. This case has also been discussed at length with the Paediatric Crisis Neurodiversity & Learning Disability Lead Nurse from SWFT.

A Patient Forum survey is going to be conducted to look at patient and family satisfaction with regard to communication. This is currently under construction and is expected to be finished by the end of June 2026.

The Trusts would like to thank the coroner’s office again for the opportunity to review and strengthen the pathways of care for our patients and hope this answers your outstanding concerns. As a Trust we strive for excellence in patient care and put the patient at the heart of all we do. The Trust uses incidents as an opportunity to learn and grow.

Please do not hesitate to contact me if you require any clarification.

Royal College of General Practitioners

Education

Letter dated 22 May 2026 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Royal College of General Practitioners stated it would communicate to its members how primary care information and hospital transfer methods influence secondary care pathway selection. • This communication would be delivered through a webinar format, incorporating learning from Prevention of Future Death Reports.

View full response

Dear Mrs Lee

Regulation 28 Report to Prevent Future Deaths - regarding the death of Master Ethan Michael Hanson

Thank you for asking us to comment on the matters of concern following the sad death of Master Ethan Michael Hanson, who died on the 26th of April 2025. Our sincere condolences go to his family and friends given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Ethan’s loved ones.

You have a matter of concern for GPs relating to this tragic death: The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer. To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training, promoting research, advocating and representing the College and its 56,000 members. General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. There are 5 areas of capability aligned to the General Medical Council’s Generic Professional Capabilities Framework, and these are supported by twenty-two Clinical Topic Guides. Within the Urgent and Unscheduled Care Clinical Topic Guide, areas of a GP’s role include aspects relevant to Ethan’s care: The importance of providing appropriate documentation and records for each patient contact, which must be communicated to the next professional involved with that patient Appropriate use of emergency services, including the logistics of communicating with an ambulance or paramedic crew and the response time required

Strategies for ensuring effective and appropriate communication and escalation of concern regarding deteriorating patients to ambulance services, the emergency department (ED) or accident and emergency (A&E) and acute service colleagues

Within NHS England’s 2024 ‘Same Day Emergency Care- service specification’ document the flow chart suggests Paediatric SDEC service unless NEWS2 score of over 5, or a score of 3 in a single parameter, in which case referral to Emergency Department is indicated- it is not clear if that threshold applied here. There is no reference in this specification to primary care communication, nor in the 2026 ‘Model Acute Pathway: standards for care of acutely unwell patients in their first 72 hours in hospital’, developed with the Royal College of Physicians, Society for Acute Medicine and British Geriatrics Society, which emphasises availability of senior clinical decision making, usually working at Medical Registrar level. Work on the interface between primary cand secondary care included a joint statement between RCGP, RCP, SAM and Royal College of Emergency Medicine calling for secondary care to improve primary care access to specialist advice via dedicated telephone lines and urgent expansion of SDEC options for primary care and 111 services. GP Awareness of impact of referral letter and ambulance conveyance on clinical pathways within Emergency care, opportunities to communicate this to GPs. GP Information Technology Systems record GP Consultations and information such as recorded in Ethan’s GP encounter. There is no single GP IT System and suppliers include EMIS, SystmOne and Medicus. There is no single Hospital IT System and given this situation, information sharing between Primary and Secondary care faces challenges. GPs are faced with a choice under time pressures given observations as recorded in Ethan’s consultation, to admit via Paediatric colleagues or direct to the Emergency Department. Secondary care pathways will differ between organisations. From a primary care perspective, it may seem that the most direct means of rapid assessment will be through ED. Added awareness that primary care information and method of hospital transfer influences secondary care pathway selection needs to be highlighted to GPs if the existing secondary care pathways remain as described. I intend to communicate this issue to members alongside learning from Prevention of Future Death Reports in a Webinar format for dissemination of learning, ensuring principles being highlighted are generic and not attributable to individual cases, nor impacting ongoing proceedings that follow each coronial review. Once again, our condolences go to Ethan’s family and friends. I hope the comments provide a full picture of where the RCGP can influence the prevention of future deaths within training and continuing professional development.

NHS England

PDF

AI-classified response stance Action Planned

AI-generated response summary

NHS England plans to update the GIRFT pathway to emphasize GP referral to surgical teams and will ensure learning from the case is reflected in system discussions and professional communication. While supporting George Eliot Hospital's planned new EPR system by March 2027 and launching a new Frontline Productivity Programme, NHS England does not consider changes to the GP contractual framework necessary.

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ethan Michael Hanson who died on 26 April 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 March 2026 concerning the death of Ethan Michael Hanson on 26 April 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ethan’s parents and family. NHS England is keen to assure the family and yourself that the concerns raised about Ethan’s care have been listened to and reflected upon. Your Report raised concerns around the following:
1. The absence of computerised mandatory-field safeguards to prevent incorrect or incomplete recording of observations or pain scores.
2. The triage pathway design is not fully aligned with national GIRFT guidance
3. GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
4. Local processes provide no structured support for neurodivergent children or parents
5. Critical GP information is not carried forward into the hospital assessment. Getting It Right First Time (GIRFT) Guidance GIRFT clinical leads held a meeting to discuss your Report for Ethan. The GIRFT pathway for acute abdominal pain and appendicectomy (2022) advocates eight quality improvement areas which include consistent approaches to pain assessment, adoption of a defined diagnostic pathway, and consistent identification of the sick child using the National Paediatric Early Warning System (NPEWS) with appropriate early management. This had been developed following a systematic review of evidence and co-developed with clinicians from primary care, emergency care, radiology, anaesthesia, surgery, 111 and paediatrics. GIRFT clinical leads at the meeting discussing your Report agreed that the care delivered in this case did not align with the GIRFT pathway. In this particular case Ethan arrived without any documented evidence they had been referred which meant that the wrong team saw him. As this was a GP referral it should

[Page 2] have been directed to a specialist, but as it wasn't signposted as a GP referral, this didn’t happen. The GIRFT pathway for acute abdominal pain and appendicectomy is not intended as a replacement for undergraduate and postgraduate medical teaching on the pathophysiology, assessment and treatment of children presenting with acute illness, it is an adjunct adoption of best practice. As per any pathway dealing with acute illness safety netting advice is critical. The GIRFT Abdominal Pain and Appendicitis best practice pathway clearly states the need to provide families with patient information at discharge. This is further defined in the consensus recommendations document (Acute-Paeds-Abdominal-Pain-Pathway- literature-review_4.pdf). Families should receive safety netting advice with who, when and how to contact the appropriate person if they have a concern about their child after discharge. It was agreed that the GIRFT pathway will be updated to emphasize that the GP should refer specifically to the surgical team, although in this case a referral was not made to any team by the GP. There is a long-standing requirement to provide reasonable adjustments under the Equality Act 2010 and this forms part of the autism strategy issued under Section 1 of the Autism Act 2009. The Oliver McGowan Code of Practice on statutory learning disability and autism training 2025 and associated Tier 2 training covers provider and healthcare staff duties to assess and support neurodivergent people who may also be parents or carers. Clinical and operational policies should reinforce the key principles of the Oliver McGowan training to support staff in their approach to the assessment, care, treatment and support of neurodivergent people who are patients, parents and/or carers and should be co-produced to ensure they are appropriate and effective. The Health and Care Act 2022 introduced a requirement that registered providers (in this case the GP practice and George Eliot Hospital) must ensure staff receive training on learning disability and autism which is appropriate to the person’s role. The training package must meet the standards set out in the code, which the CQC also assesses. If the Oliver McGowan training principles had been followed in this case, it would likely have resulted in an increased level of concern from the GP, which would have reinforced the need for a letter to accompany the patient and parent to the emergency setting and/or prompted a call to the hospital by the GP to arrange review as recommended in the GIRFT abdominal pain pathway. However, an emergency presentation without the letter should not have negated the need for robust clinical evaluation, examination and investigation within the Emergency Department (including use of NPEWSGIRFT colleagues have advised that adherence to standard processes of care would have identified that Ethan was seriously unwell, irrespective of his diagnosis of neurodivergence. The Royal College of Paediatrics and Children’s Health (RCPH) standards for emergency care for children and young people also highlights how to appropriately care for autistic children and young people and those with a learning disability, as well

[Page 3] the appropriate standards of support and communication that should be afforded to parents and carers. Critical GP information is not carried forward into the hospital assessment NHS England notes the Coroner’s concern regarding the potential for important clinical information identified in general practice not to be readily visible during subsequent hospital assessment, particularly where children attend hospital by self-presentation rather than through formal clinician to clinician referral routes. Having considered this, NHS England does not consider that this case identifies a need for changes to the GP contractual framework. However, we recognise the importance of reinforcing good professional practice at primary–secondary and urgent and emergency care interfaces, particularly for children with suspected serious illness. General Practitioners are already required to practise in line with the GMC’s Good Medical Practice, including the duties to communicate clearly, share relevant information to support continuity and safety of care, and to raise concerns where they believe patients may be at risk. NHS England supports these professional standards and the expectation that clinicians use their judgement to ensure that relevant clinical findings and concerns are communicated appropriately when arranging onward care. GMC’s Good Medical Practice Guidance at section 21 and 23 which relates to delegation and referral regarding the responsibilities of clinicians states: 21 You must pass on to the medical, health, or social care professional or service provider involved:
a. relevant information about the patient’s condition and history
b. the purpose of transferring care and/or the investigation, care or treatment the patient needs. 23 You must record your work in line with paragraphs 69–71 of Good medical practice and use the systems available to you effectively, particularly when you will not see the patient again NHS England routinely seeks to support the sharing of learning and best practice across primary care. In response to this Prevention of Future Deaths Report, NHS England will ensure that the learning identified is reflected in system discussions and professional communication, with a particular focus on:
• awareness of how different routes of referral into hospital care may affect triage and assessment pathways; and
• the importance of clear communication of clinical concerns and abnormal findings when children are advised to attend hospital urgently. NHS England will continue to promote system learning and improvement at the interface, rather than introducing prescriptive new requirements, recognising that safe

[Page 4] care depends on effective professional judgement, communication and joint working across the system. Frontline Digitisation (FD) Programme NHS England has developed and led the frontline digitisation (FD) programme, supporting NHS Trusts with adoption of Electronic Patient Record (EPR) systems to support increased consistency in digital maturity and improve information sharing within and between organisations. Beyond facilitating the procurement of EPR systems, the FD programme also provides guidance and support to ensure safe and effective deployments. At present, George Eliot Hospital NHS Trust continues to operate the DXC Lorenzo Electronic Patient Record (EPR) system. The Trust secured multi-year funding through the FD programme to implement a new EPR, Oracle Health, with a current planned Go-Live date of 15 March 2027. George Eliot Hospital NHS Trust is working in partnership with South Warwickshire University NHS Foundation Trust on a joint EPR programme and will be joining the existing University Hospitals Coventry and Warwickshire EPR instance, which went live on 17 June 2024. This approach will support the delivery of a unified care record across all three organisations. Local EPR implementations should have oversight from a Trust Clinical Safety Officer (CSO), a registered healthcare professional responsible for overseeing the clinical safety and risk management of health IT systems, ensuring they are safe for patient use. Digital safety is an important part of patient safety. Suppliers alongside Trusts are accountable for compliance with two mandatory Clinical Risk Management Standards defined under Section 250 of the Health and Social Care Act 2012:
• DCB0129
• DCB0160 DCB0160 relates to deployment of Health IT Systems and is intended to be an ongoing, iterative process rather than a one-time assessment. All modifications to the EPR, including system updates, configuration changes, or incidents, must be proactively evaluated for their potential impact on patient safety throughout the entire lifecycle of the system. Any identified hazards or potential scenarios of patient harm, such as those arising from system functionality, configuration, or user error must be documented in a ‘Hazard Log’. This log should be continuously maintained and updated to reflect new incidents, along with the corresponding controls or mitigations implemented. NHS Trusts are required to operate formal incident management systems to support the monitoring, reporting, and investigation of clinical incidents or near misses associated with the use of the EPR system. These systems must facilitate organisations learning, drive process improvements, and ensure that necessary changes to the EPR system are implemented in response to identified issues.

[Page 5] The specific details of the data error in this case will need to be investigated with the George Eliot Hospital NHS Trust. DSB0129 and DCB0160 are mandated standards that should ensure any recorded observations fall within agreed parameters and are designed to reduce entry and transposition errors. The data entry fields should be reviewed and any potential risks (such as incorrect values being entered) picked up on end user testing. Staff should be fully trained in the use of the EPR to ensure they fully understand the importance of correct and complete data entry in the relevant data fields. It is essential that the FD programme continuously learns and evolves by drawing insights from assurance activities related to local EPR implementations, other digital health technology initiatives, and recognised examples of good practice. The NHS England FD programme team plays a pivotal role in the continuous improvement cycle by actively promoting and disseminating lessons learnt. These insights inform enhancements to the support offer and drive system-wide improvements through collaboration, knowledge sharing, and the application of actionable learning. Further investment in digital transformation has been confirmed for the Frontline Productivity (FP) Programme FD programme, a four-year initiative commencing in April 2026. This programme is designed to enable NHS organisations to fully realise the benefits of digitising patient data by advancing the optimisation of EPR capabilities. Building on the experiences and lessons from preceding programme such as FD, the FP programme will also support the analysis of digital health events to uncover root causes and inform the refinement of processes and systems for future resilience and effectiveness. The newly published Fit for the Future: 10 Year Plan for England, sets out the government’s plan for healthcare in England over the next 10 years, which includes a commitment to give patients ‘a single patient record (SPR) – to enable more coordinated, personalised and predictive care’. In any given clinical setting healthcare professionals should be able to see all patient contacts prior to arrival in that setting, but this currently doesn't happen. Rather than build a SPR record from scratch, a likely solution may include even better interoperability between the many systems in operation, as NHS England is aware of the challenge in sharing medical records and results within and between all organisation (including social care and commissioned organisations) that use different technologies. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Ethan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

[Page 6]

Report sections

Circumstances of the death

Ethan was autistic and was awaiting an ADHD diagnostic assessment. On the morning of 23 April 2025, he was seen by his GP because of abdominal pain, vomiting and concern about a serious underlying cause, including appendicitis. The GP accurately recorded a raised temperature and tachycardia. No ambulance was summoned and no written referral letter was provided. The GP advised that Ethan should go directly to hospital with his mother, apparently without appreciating that self-presentation would place him on a different pathway at George Eliot Hospital than if he had arrived by ambulance or with written referral details.

On arrival at George Eliot Hospital, Ethan was triaged “yellow” and assessed by an Advanced Nurse Practitioner. As no referral letter accompanied him, the GP’s findings and concerns were not available to the assessing clinician. No urine dipstick or blood tests were undertaken. Ethan reported severe pain, scoring 10/10, but no clinician-assessed pain score or repeat observations were performed. A transposition error occurred in the recording of oxygen saturation and temperature. A phosphate enema was given for presumed constipation. A senior medical review did not take place prior to discharge.

Evidence was given that, had the correct temperature reading been recorded, Ethan would have been escalated for registrar or consultant review. Evidence was also given that, by a consultant surgeon that had he reviewed Ethan at the time, appendicitis would likely have been diagnosed, though in his opinion not every clinician would have necessarily done so.

Hospital staff perceived Ethan and his mother to be content with the plan and comfortable with discharge. Ethan’s mother explained that she is neurodivergent, was frightened and remained concerned, but was unable to articulate disagreement or challenge the decision at the time.

After discharge, Ethan deteriorated. On 25 April 2025 he collapsed at home and suffered cardiac arrest. He was resuscitated and taken to University Hospitals

Coventry and Warwickshire, where imaging confirmed perforated appendicitis, generalised peritonitis and sepsis. He was transferred to Birmingham Children’s Hospital but died on 26 April 2025.

George Eliot Hospital does not undertake operative management for paediatric appendicitis, and children requiring surgery are transferred to Leicester or to University Hospitals Coventry and Warwickshire. This configuration increases the importance of early recognition and escalation at initial presentation, and means the Trust has less exposure to operative cases than a centre providing surgical treatment.

The Trust carried out a review following Ethan’s death and made several recommendations. Evidence heard at the inquest indicated that the steps taken did not fully address the issues identified in this case.

Action should be taken

In my opinion action should be taken to prevent future deaths and I believe your organization has the power to act.

Copies sent to

Copies have also been sent toUniversity Hospitals Coventry and Warwickshire NHS TrustBirmingham Women’s and Children’s NHS Foundation TrustDeceased’s GP Practice Linda Lee Acting Area Coroner for Coventry and Warwickshire Date: 30 March 2026

Similar PFD reports

Shared signals

Report details

Reference: 2026-0229
Coroner: Linda Lee
Coroner area: WarwickshireThis report is being sent to: NHS England, George Eliot Hospital NHS Trust | College of General Practitioners

Responses identified

Responses identified 4 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 May 2026 (stated in the report).

Sent to

College of General Practitioners

NHS England, George Eliot Hospital NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.