“The lack of serial nursing observations was a fundamental omission from Finlay’s care”

The 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: 2 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0316

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0