“As you will see from the attached narrative conclusion, whilst at King’s Martha was not…”
Dated 28 Feb 2022, from the coroner for Inner North London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 25 Apr 2022.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated28 Feb 2022
- Deadline25 Apr 2022
- Published on judiciary.uk3 Mar 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| King's College Hospital NHS Foundation TrustNamed in the report as “King’s College Hospital NHS Foundation Trust” | Response publishedPublished on judiciary.uk in March 2022. |
The coroner’s concerns
As you will see from the attached narrative conclusion, whilst at King’s Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries. 1. I heard that the bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to me very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring. 2. The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. I heard evidence that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach. However, the intended programme has stalled, I think partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future.
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, 2022-0063
- 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
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