“There were insufficient trained Paediatric nurses on duty in the Emergency Department…”

The coroner’s concerns

– 1. There were insufficient trained Paediatric nurses on duty in the Emergency Department (ED), on the day of Meha’s admission, and there was no effective escalation to senior nursing staff to highlight this 2. There was overall a lack of recognition of how unwell Meha was on admission and over the subsequent hours prior to her death- this included both nursing and medical staff in ED 3. Whilst switching from use of POPS to PEWS in ED, is likely to assist in ensuring repeat observations in a sick child, a PEWS of 6-8 only triggers review by a junior rather than a senior ED Doctor, the former less likely to recognise severity of illness and respond appropriately 4. There was insufficient and ineffective handover between medical staff, with lack of documentation of key information, and agreed clinical plansbetween doctors in ED, and between ED and Paediatric staff I am not reassured that necessary actions to address these serious issues identified are in place.

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, 2024-0187

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