A North London hospital is ‘determined to learn’ after an inquest found a failure in nursing observations denied a toddler the chance to survive. Finlay Roberts was just two years and 11 months old when he attended the Whittington Hospital in Archway – tragically it was on a night when the paediatric emergency department was ‘extremely busy’ and understaffed.
An inquest at Inner North London Coroner’s Court heard there was a failure to do nursing observations; not all tests were carried out appropriately; and specialist advice sought from Great Ormond Street Hospital was not received before Finlay’s discharge, due to the late arrival of X-rays, a lack of complete information, and a failure to close the communication loops.
Finlay died from a twisted bowel condition – sigmoid volvulus – which Coroner Mary Hassell said was ‘a rare (in a child) but recognised natural cause’. “It is unclear whether different hospital care that night would have saved Finlay’s life. It would have given him a chance,” added the coroner.
In a prevention of future deaths report to the Trust, Ms Hassell said although she had heard evidence of ‘many improvements’ at the department since Finlay’s death, she remained concerned the wider issue of nursing observations, and a failure to recognise this by medical staff, as she had also written to the Royal Free this year about similar issues after the death of Billie Wicks.
Billie, 16, died after her first ever asthma attack after she was sent home from the A&E department of the Hampstead hospital. At the inquest into her death, Ms Hassell also heard about staffing issues. Ms Hassell previously wrote to the Royal Free about observations after the inquest for Daniel Klosi, who was taken to hospital four times with sepsis in the run up to his death in 2023.
Raising her concerns about Finlay’s death, Ms Hassell wrote: “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.
“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.”
What happened?
The inquest heard Finlay was taken to Whittington Hospital’s Paediatric A&E department on the advice of the family GP after he woke with tummy ache on the morning of July 11, 2024. Finlay’s dad, David Roberts, described his experience in the hospital as the ‘stuff of nightmares’, being left to spend ‘nine hours sitting on chairs’ in the corridors.
It was so busy, David said, that ‘key examinations’ were being carried out in the corridors while Finlay was sitting on his knee. David and Finlay’s mum Elizabeth asked for a transfer to Great Ormond Street on multiple occasions to access tests the Whittington were unable to provide – but were rebuffed.
During his time at the department, from 4:15pm on July 11 to 1am on July 12, Finlay only had one set of partial observations through the whole nine hours. This was despite evidence from doctors to the inquest that observations should be done at least every four hours in the emergency department. Finlay was ultimately discharged and told to come back the next day, without any observations.
At around 8am, Finlay’s mum found him lifeless in the bed next to her and not breathing. David desperately tried to resuscitate his son, and these efforts were continued by paramedics and later doctors at the Whittington Hospital, but he died the same day, exactly a month before his third birthday.
‘We desperately wish there could have been more’
Finlay’s parents, David and Elizabeth Roberts, said: “We are simply devastated by Finny’s death. He was the happiest and most loved of little people. Our lives will never be the same. We remain thankful for the nearly three years we had with him they were filled with joy and happiness. We desperately wish there could have been more. We have set up ForFinny.com to raise money for charities in his memory.”
Leigh Day partner Maria Panteli, representing the family in court, said: “Elizabeth and David Roberts have shown remarkable courage as they have navigated this difficult process. Finlay’s death has shone a light on the importance of serial nursing observations and highlighted staffing issues within the Whittington’s paediatric emergency department.
“In response to Finlay’s death, we understand the Whittington has since hired more nursing staff. In light of the coroner’s Prevention of Future Deaths Report, we hope that a thorough review of practices and policies at the Whittington may serve to prevent similar instances occurring.”
In response to the report, a Whittington Health NHS Trust spokesperson told MyLondon: “We offer our sincere condolences to Finlay’s family. Following an investigation led by a consultant from an external organisation, we have made changes to our services.
“We are also planning further improvements based on the coroner’s findings around how we conduct and record observations. We are determined to learn from the heartbreaking events around Finlay’s death and improve the care and support that we provide.”
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