Billie Wicks

Coroner ME Hassell 

Senior Coroner  
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

02 May 2025 

Dear M. E Hassell. 

Firstly, may we pass on my condolences to the family and friends of Billie Wicks.  We appreciate the 
opportunity to comment on the issues raised by HM Coroner.   

Staffing 
We are unable to comment about the staffing model, numbers, or skill mix, at The Royal Free Hospital’s 
emergency department.  The Royal College of Emergency Medicine (RCEM) has guidance regarding 
the level of staffing for doctors [1], nurses, and healthcare staff [2]. In December 2024, the RCEM also 
published standards around staffing [3]. Each ED should have a senior decision-making (tier 4) doctor 
in the department at all times [3, 7]. A tier 4 doctor may be referred to as a registrar. Adequate staffing 
is required to deliver safe care. 

Physiological Observations 
Each emergency department (ED) should have a track and trigger tool for children (of all ages) [3] and 
adults. There are several different scores that are referred to as PEWS.  The national paediatric early 
warning  system  (nPEWS)  was  designed  for  inpatient  use,  and  a  new  ED  version  is  currently  being 
developed and tested. NEWS2 and nPEWS both include  blood pressure monitoring. RCEM and the 
Royal College of Paediatrics and Child Heath, do not currently support the use of nPEWS in the ED 
[5,6]. It is acceptable to use the adult national early warning score (NEWS2) in children aged 16 and 
above [4]. Both nPEWS and NEWS2 have suggested frequency of repeat observations depending on 
the initial set of observations performed.  

Listening to parents & carers 
The nPEWS and the EDnPEWS that is being developed both contain a section to record parental/carer 
concern and this is included in the escalation advice. RCEM is supportive of the testing of Martha’s 
Rule in the ED setting. 

Antibiotic administration 
It  is  good  practice  for  the  prescribing  and  administration  of  medicines  to  be  performed  by  different 
practitioners [8].  There is current guidance on the management of sepsis. This would suggest that for 
sepsis without shock, antibiotics should be administered within  three hours [9].  It is unclear whether 
Billie had sepsis. Guidance for the time to administer the first dose of antibiotics in people with infection 
without sepsis are less proscriptive.  RCEM notes that Billie was discharged after about  three and a 
half hours. It is assumed that she was given antibiotics at discharge, to self-administer. Antibiotics are 
only  part  of  the  management  for  an  exacerbation  of  asthma  thought  to  be  secondary  to  a  bacterial 

 
 
 
 
 
 
 
 
 
 
 
 infection.  Exacerbations of asthma in childhood are often secondary to viral infection; if this was the 
case, the timing of the first dose of antibiotics is irrelevant. It is unclear if Billie was given any steroids 
or received any other acute management for asthma.  RCEM are not aware of any national guidance 
or clear rationale which would support a directive that, in the absence of suspected allergy, the first 
dose of an antibiotic needs to be administered by a clinician. 

Recognition of Adult-onset Asthma 
Billie was 16 years old, whilst legally a child, for the purposes of assessment and treatment of asthma 
it may have been appropriate to have managed her as an adult [10].  There are national guidelines 
around the management of acute exacerbations of asthma, as well as the diagnosis of asthma [11,12].  
RCEM has learning resources regarding asthma diagnosis and treatment.  This highlights that one in 
four patients are not diagnosed with asthma until an adult [13,14], and asthma is part of the curriculum 
for post-graduate doctors in training [15]. 

Safety Netting 
ED  clinicians  will  often  see  patients  and  discharge  them  home  knowing  that  there  is  a  possibility 
(however small) that their condition might deteriorate.  

RCEM shares your concerns regarding the use of the term ‘safety netting’ in medical notes. This term 
is  only  of  value  if  the  components  of the  ‘safety net’  have been  documented.    RCEM  considers the 
components which relate to safety netting (as opposed to other information which might be provided to 
the patient) to include: [18]  

•  What symptoms to look out for which suggest condition is not getting better 
•  What symptoms should necessitate review in the community (GP) 
•  What symptoms should necessitate review back in the emergency department or the need to 

telephone 999  

•  What, if any, follow-up is required 

This is in keeping with the information contained in many patient information leaflets produced by the 
NHS  [16] relating  to  conditions  which may  present to  an  emergency  department  and  be  suitable for 
discharge, including asthma [17].  The provision of standard written advice or access to online material 
via a QR code is ideal [18].  RCEM will update its existing guidance on the provision of information to 
patients to specifically address the issue of ‘safety netting’, we are grateful to you for bringing this issue 
to our attention. 

Yours sincerely,  

Chair, Quality in Emergency Care Committee 
Royal College of Emergency Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 References 

1. Royal College of Emergency Medicine. (2019). RCEM Workforce Recommendations 2018: 
Consultant Staffing in Emergency Departments in the UK (Revised February 2019). Retrieved from 
https://rcem.ac.uk/wp-
content/uploads/2021/11/RCEM_Consultant_Workforce_Document_Feb_2019.pdf  

2. Royal College of Nursing & Royal College of Emergency Medicine. (2020). Nursing Workforce 
Standards for Type 1 Emergency Departments. Retrieved from https://res.cloudinary.com/studio-
republic/images/v1635683394/RCN_RCEM_Nursing_Workforce_Standards_2020/RCN_RCEM_Nurs
ing_Workforce_Standards_2020.pdf  

3. Royal College of Emergency Medicine. (2024). Guidelines for the Provision of Emergency Medicine 
Services (GPEMS). Retrieved from https://rcem.ac.uk/wp-content/uploads/2025/01/GPEMS-Jan-
2025.pdf 

4. Royal College of Physicians. (2017). National Early Warning Score (NEWS) 2: Standardising the 
assessment of acute-illness severity in the NHS – Executive Summary and Recommendations. 
London: RCP. Retrieved from https://www.rcp.ac.uk/media/ctulqqbn/news2-executive-summary_0.pdf 

5. Royal College of Emergency Medicine. (2024). RCEM Position Statement: Paediatric Early 
Warning Scores. Retrieved from https://rcem.ac.uk/wp-content/uploads/2024/01/RCEM-Position-
Statement-Paediatric-Early-Warning-Scores-Jan-2024-FINAL.pdf 

6. Royal College of Paediatrics and Child Health. (2024). UK Paediatric Early Warning Systems 
(PEWS). Retrieved from https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems#_0-
should-we-be-using-the-national-pews-in-emergency-departments 

7. Royal College of Emergency Medicine. (2025). Revised Position Statement on RCEM Workforce 
Tiers. Retrieved from https://rcem.ac.uk/wp-content/uploads/2025/02/Tiers2-February-2025.pdf 

8. Royal Pharmaceutical Society. (2024). Prescribing and Dispensing by the Same Healthcare 
Professional: Position Statement. Retrieved from https://www.rpharms.com/recognition/all-our-
campaigns/policy-a-z/prescribing-and-dispensing 

9. Academy of Medical Royal Colleges. (2022). Statement on the Initial Antimicrobial Treatment of 
Sepsis (Version 2, October 2022). Retrieved from https://www.aomrc.org.uk/wp-
content/uploads/2022/10/Statement_on_the_initial_antimicrobial_treatment_of_sepsis_V2_1022.pdf 

10. Resuscitation Council UK. (2022). Paediatric Emergency Algorithms & Resources (Version 1, 
March 2022). Retrieved from https://www.resus.org.uk/sites/default/files/2022-
03/RCUK%20Paediatric%20emergency%20algorithms%20and%20resources%20Mar%2022%20V1.
pdf 

11. National Institute for Health and Care Excellence (NICE). (2024). Asthma: Acute Exacerbation 
Management. Clinical Knowledge Summary. Retrieved from 
https://cks.nice.org.uk/topics/asthma/management/acute-exacerbation-of-asthma/ 

12. National Institute for Health and Care Excellence (NICE). (2024). Asthma: Assessment. Clinical 
Knowledge Summary. Retrieved from https://cks.nice.org.uk/topics/asthma/diagnosis/assessment/ 

13. Royal College of Emergency Medicine. (2021). Asthma in Adults. RCEMLearning. Retrieved from 
https://www.rcemlearning.co.uk/reference/asthma-in-adults/ 
14. Context - RCEMLearning 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 15. Royal College of Emergency Medicine. (2019). The Syllabus. Retrieved from 
https://rcemcurriculum.co.uk/the-syllabus/ 

16. National Health Service (NHS). (n.d.). Health A to Z. Retrieved April 14, 2025, from 
https://www.nhs.uk/conditions/ 

17. National Health Service (NHS). (2024). Asthma. Retrieved April 14, 2025, from 
https://www.nhs.uk/conditions/asthma/ 

18. Royal College of Emergency Medicine. (2023). Best Practice Guideline: Providing Patient 
Information in the Emergency Department. Retrieved from http://rcem.ac.uk/wp-
content/uploads/2023/10/RCEM_Best_Practice_Providing_Information_in_the_Emergency_Departme
nt.pdf

Coroner ME Hassell  
Senior Coroner  
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London N1C 4PP 

12 May 2025 

Sent by email to:  

Dear Mr. Hassell,  

Re: RCPCH Response to the Inquest Touching the Death of Billie Diane Wicks 
A Regulation 28 Report – Action to Prevent Future Deaths 

Thank you for sharing your report with us regarding the tragic and untimely passing of Billie 
Diane Wicks. I was very sorry to hear of Billie’s death. I have shared your report with 
colleagues within RCPCH. 

We have considered your report carefully. Of the five matters noted, we believe two are of 
particular note to the Royal College of Paediatrics and Child Health given our work on 
standards of paediatric care in the Emergency Department and our work to implement the 
Paediatric Early Warning Systems (PEWS) process across the four nations. 

1.  I heard repeatedly that on the night Billie attended, the Royal Free emergency 

department was understaffed, and that it remains understaffed of doctors, nurses, 
and even a healthcare assistant who could take basic observations. Billie should 
have had observations every hour. 

From the information provided we do not know many observations (if any) Billie had during 
her five hour stay in ED.  Observations are important but are part of a holistic assessment of 
children. There are lots of reasons why observations might not be obtainable, however 
RCPCH recognises that challenges are significantly exacerbated by gaps in clinical rotas 
resulting in understaffed departments. In 2024, RCPCH carried out work to better 
understand where rota gaps most prominently impact paediatrics, and we continue to 
advocate at a local and national level for an active reduction in these gaps1.  

Our Facing the Future standards aim to provide a vision of how paediatric care can be 
delivered to provide a safe and sustainable, high-quality service that meets the health needs 
of every child and young person. There are standards covering emergency settings. It is not 
clear from the report whether Billie was treated in an adult or paediatric emergency 
department, however RCPCH is clear that our Facing the Future: Emergency Care 

1 RCPCH Rota Gaps Survey Report. 2024. Available from: https://www.rcpch.ac.uk/resources/rota-gaps-2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Standards apply to all persons up until the age of 18, regardless of where they are treated. 
These standards aim to ensure that urgent and emergency care is fully integrated to ensure 
children are seen by the right people, at the right place and in the right setting. 
We are currently in the process of audit, review and revision and update of our current 
standards, to be published later in 2025.  

One of the current Emergency care standards has particular relevance: 

•  Standard 17 – All children attending emergency care settings are visually assessed 
by a doctor or nurse immediately upon arrival with clinical assessment undertaken 
within 15 minutes to determine priority category, supplemented by a pain score and a 
full record of vital signs. 

As mentioned, these standards are currently being updated and the new version will set out 
that observations are part of holistic care and repetition is dependent on the child’s well-
being, alongside clarification around frequency of observations. 

2.  I understand that blood pressure is not yet an observation included in the national 

paediatric early warning score (PEWS). 

I can confirm that blood pressure is now an observation included in the national paediatric 
early warning score (PEWS). The PEWS score consists of: Heart Rate, Respiratory Rate, 
Extent of Respiratory Distress, Blood Pressure, Oxygen Saturations, Oxygen Delivery and 
Capillary Refill Time (CRT).   

RCPCH have been collaborating with NHS England and the Royal College of Nursing to 
develop a single national PEWS for England since 2018 and are supportive of equivalent 
processes across the UK.  

Thank you for seeking our views and reminding us of the importance of this work. Our 
sincere condolences are with Billie’s family.  

Yours sincerely 

RCPCH President

Royal Free London Hospital Group, 
Pond Street, 
 London  
NW3 2QG 
Phone: 020 7794 0500 

Private and Confidential 
His Majesty’s Senior Coroner Mary Hassell  
St Pancras Coroner’s Court 
Camley Street 
London  
N1C 4PP 

Via Email  

12 May 2025  

Dear Madam,  

Re: Regulation 28: Prevention of Future Deaths report – Billie Wicks (date of death: 15 
September 2024) 

We write to you in response to the Regulation 28: Prevention of Future Deaths report following 
the inquest into the death of Billie Wicks     

We would like to reiterate our sincere condolences to the family of Billie for their loss. 

The  Royal  Free  London  NHS  Foundation  Trust  has  carefully  considered  the  matters  of 
concern raised in the Regulation 28 Report.  

We are grateful for the opportunity to respond to the matters you have raised and would like 
to  start  by  assuring  you  that  this  safety  event  has  been  reviewed  as  part  of  our  routine 
governance process, prior to the inquest. The Trust reviewed this safety event at the Patient 
Safety Event Review Panel (PSERP) on 25 September, where it was agreed that a Patient 
Safety  Incident  Investigation  (PSII)  would be  undertaken. The  PSII  was  completed  and  the 
findings shared with Billie’s family in advance of the inquest. 

The inquest took place on 6 March 2025 and raised several matters of concern which have 
been responded to below:  

1.  At  inquest,  I  heard  repeatedly  that  on  the  night  Billie  attended,  the  Royal  Free 
emergency department was understaffed, and that it remains understaffed of doctors, 
nurses,  and  even  a  healthcare  assistant  who  could  take  basic  observations.  Billie 
should  have  had  observations  every  hour.  If  she  had  had  these  observations,  the 
emergency registrar who discharged her would have recognised that she was not as 
well as he thought and would have sought senior medical review. That senior medical 
review  would  have  changed  the  course  of  her  management  and  saved  her  life. 
Following the inquest touching the death of Daniel Klosi, I wrote to you on 16 August 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2024  about  a  lack  of  observations  in  the  emergency  department  of  the  Royal  Free. 
Although the circumstances were different, there is a theme. 

It  is  acknowledged  that  on  the  night  Billie  attended  the  Royal  Free  Hospital  Emergency 
Department, there was a failure to recognise the significance of her abnormal observations, 
resulting  in  Billie  being  discharged  inappropriately.  The  lack  of  repeat  observations  is  also 
recognised  as  an  ongoing  theme  which  has  been  extensively  addressed  and  a  number  of 
measures, already in place, have been detailed in this response. It is noted that patients in the 
emergency department are required to have hourly observations whilst they remain abnormal. 
In Billie’s case her observations remained abnormal, therefore a further set of observations 
would have prevented her discharge from the department. To further address these concerns, 
the following actions have been taken: 

•  Emergency  department  paediatric  consultant  cover  has  been  augmented  since  this 
incident  and  is  now  consistently  scheduled  every  day  between  09:00  -  23:00  hrs 
Monday to Friday, providing senior supervision during these hours to the middle grade 
doctors  working  in  this  area,  maintaining  robust  training  and  guidance  during  these 
hours to enable improved decision making and increased confidence overnight. 

•  Following this safety event, all paediatric patients with abnormal vital signs must be 
referred to Paediatrics prior to discharge, the guideline has been updated and shared 
to reflect this requirement. 

•  Access to an onsite Paediatric consultant is available 24/7 and an emergency medicine 
consultant is available 24/7 through the on-call system if needed to support the above 
action.  

•  All  new  doctors  starting  in  the  Emergency  Department,  now  receive  a  mandatory 
teaching session at induction focusing on paediatrics and paediatric deterioration and 
escalation with regular sessions timetabled ongoing to maintain this education.  

• 

In addition to these measures, this case has been shared on multiple occasions during 
Paediatric  and  ED  Mortality  and  Morbidity  (M&M)  meetings,  hospital  wide  safety 
briefings across all divisions as shared learning.  

•  Nurse staffing on the night of Billie’s first attendance on 14th September 2024 was in 
line  with  the  nursing  establishment  levels  of  safe staffing  except for  one  Registered 
Nurse (RN) rota gap during the day shift prior to Billie’s attendance. In the interim the 
trust has approved additional staffing to medical and nursing shifts, filled by bank and 
agency staff to mitigate staffing to the levels described in the business case based on 
safe  staffing  skill  mix  assessment  and  the  level  of  acuity  /  complexity  of  patients 
attending in the Royal Free Hospital emergency department. 

•  Long-term mitigation of the current establishment is anticipated and is associated with 
the trusts process of business case approval. However, in the interim we are achieving 
the  augmented  staffing  levels  with  bank  and  agency  shift  cover  until  we  have  the 
reconfigured and augmented establishment approved. This will increase the number 
of senior staff on shift as well as supplement the paediatric team with an Emergency 
Department Assistant (EDA) 24/7. This is a non-registered clinical member of staff who 
can  take  on  duties  similar  to  a  Health  Care  Assistant/Support  Worker  including 
performing and recording observations on paediatric patients. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2. The registrar who saw Billie the night before her death prescribed an antibiotic, but 
he was not in the habit of giving the first dose in the department and he did not on this 
occasion. This meant that Billie’s infection was not tackled as quickly as it could have 
been. This seems to indicate a training and potentially a guideline need. 

The  addition  of  an  ED  pharmacist  would  support  reliable  stocking  of  medications,  provide 
access to critical medications out of hours, education throughout the department and provide 
continuous  and  vital  expertise.  The  lack  of  pharmacy  resource  within  the  Emergency 
Department is noted to be an area of concern. It is recognised and is continually monitored, 
risk mitigations have been identified, and actions are currently being driven to try to resolve 
this in the form of a business case. The business case is currently progressing through an 
approval process with a comprehensive action plan in place whilst this gap remains.  

Whilst this work is being undertaken steps have been put in place to reinforce that when 
indicated medications should be started in the department and given as ‘To Take Away’ 
(TTA) medications. This education has already commenced in the doctor’s induction 
programme and will continue going forwards.  

This pharmacy resource has also been explored in greater detail in the Patient Safety 
Incident Investigation (PSII) and appropriate actions have been added to monitor progress of 
the business case previously referred to. An additional action to ensure there is sufficient 
supply of medication in the adult TTA stock cupboard in the Emergency Department and to 
include medication stock responsibilities in job planning has been agreed to further support 
the ED team in this area, this is being led by the Divisional Clinical Director for this area.  

After a thorough review by the multidisciplinary team (MDT) panel, it was determined that 
antibiotics were unlikely to have altered the outcome, as the infection was likely to be viral in 
nature. The panel agreed that while initiating antibiotics at an earlier stage was unlikely to 
have altered the outcome for Billie, it may well alter the course of other patients in similar 
circumstances. 

3.  At the  time  of  Billie’s presentation,  the registrar was  unaware of the  possibility  of 
adult-onset asthma. This seems to indicate a training and potentially a guideline need. 

It is acknowledged in Billie’s case, the registrar reviewing Billie did not consider a diagnosis of 
adult-onset asthma. Paediatric Asthma Wheeze Guidelines and a case study of the incident 
has been used to exemplify learning from this incident. The learning and reflections have been 
delivered at the ED Mortality and Morbidity meeting, paediatric teaching sessions to middle 
grades  and  junior  doctors,  and  is  included  within  the  Junior  Doctors  induction  plan.  The 
intended  effect  is  to  enhance  awareness  of  the  guideline  and  drive  the  knowledge  and 
application of treatments for asthma. Improving awareness of the Paediatric Wheeze pathway 
has  already  commenced  including  the  implementation  of  standardised  assessments  for 
patients presenting with asthma or wheeze.  

4. I heard that Billie was safety netted when she was discharged. Her parents were told 
to bring her back if they had any concerns. I have heard this safety netting advice being 
described  many,  many  times  in  different  inquests.  What  worries  me  about  it  in  this 
context  is  that  Billie’s  parents  had  brought  her  to  hospital  because  they  were 
concerned.  They were then reassured  by  hospital  staff. It  is therefore difficult  to  see 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 how  this  particular  advice  could  be  a  meaningful  instruction.  In  reality,  her  parents’ 
initial concern was well placed, and they had responded to it appropriately by bringing 
Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct 
had been blunted by their first visit to the hospital. 

It  is  acknowledged  that  all  parents  attending  the  paediatric  Emergency  Department  are 
concerned for their children and the team rely on good history and information gathering along 
with thorough assessments to identify the most appropriate course of action to be taken. In 
this case, the primary concern was that Billie was discharged on her first attendance without 
ensuring her vital signs were within normal parameters. More specific safety netting advice 
should  have  been  given  around  the  increase  in  difficulty  breathing,  failure  to  respond  to 
treatment provided either by RFH or the GP and had Billie been discharged with more specific 
advice, she may have re-presented earlier.  To note, safety netting is a well-recognised tool 
and  ensures  patients  do  return  if  a  patient  deteriorates  and  are  reviewed  by  a  senior  ED 
clinician.    This  is  successfully  employed  in  many  cases  and  there  are  Royal  College  of 
Emergency Medicine (RCEM) guidelines that describe the process if a patient returns to an 
emergency department. 
At the Royal Free the Royal College of Paediatrics and Child Health (RCPCH) AND Healthier 
Together QR codes are available for common presentations to support safety netting advice 
given. 

5. Whilst I doubt that it would have made a difference in this case, I understand that 
blood  pressure  is  not,  yet  an  observation  included  in  the  national  paediatric  early 
warning score (PEWS) 

NHS England is rolling out a new national standardised approach of tracking the deterioration 
of children in hospital, which is scheduled for full completion, nationally by 30 September 2025. 
The Royal Free London (RFL) is currently working through the implementation of this into our 
Electronic  Patient  Record  (EPR)  system  and  aims  will  be  in  line  with  this  guidance.  It  is 
expected to be implemented at the Royal Free Hospital (RFH) by the national deadline.  

Previously there has not been published national guidance on vital signs. National PEWS is a 
new  national  guideline  and  will  include  blood  pressures.  Whilst  in  Billie’s  case  the  blood 
pressure was not taken, it was likely to have been normal and would not have changed the 
outcome in this case.  

In  response  to  this  case  a  cross-site  working  group  has  been  established  to  unify  the 
recognition and actions to be taken in a deteriorating child. This includes all Royal Free London 
(RFL) hospital sites and has multi-disciplinary membership. Meetings are held on a 2-weekly 
basis  and  the  group  oversees  the  progress  of  the  implementation  of  the  national  PEWS, 
education, staffing, guidelines and risk evaluation. 

The action plan outlined in the Patient Safety Investigation (PSII) has been provided below.  

The Trust is committed to learning from Billie’s tragic death and continuously improving patient 
safety. We will actively monitor adherence to the ongoing improvement plans and the Trust’s 
action  plan  is  set  out  below.   This  will  be  monitored  by  the  Acute  Medicine,  Emergency 
Department and Elderly Care (AMEDEC) Divisional Quality & Safety Board and the Clinical 
Performance and Patient Safety Committee.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Action Plan 
Safety action description 

Responsibility for 
monitoring/ oversight  

Action Deadline 

Evidence   

Relevant Recommendation - Staffing/ Education  

1. 

For the senior matron for the Emergency Department to continue to 
review the business case for recruitment of a Clinical Practice 
Educator (CPE), Emergency Department Assistant (EDA) and 
overall nursing staffing in the Paediatric Emergency Department. 

Senior matron, 
Emergency 
Department 

30/05/2025 

Copy of the 
business plan 

2.  Senior matron for Emergency Department to review staffing skill 

mix for day and night shifts. 

Senior matron, 
Emergency 
Department 

30/05/2025 

Copy of the 
business plan 

3.   For the senior matron for the Emergency Department to organise 
future team days with a focus on PEWS, escalation of abnormal 
observations and observations on discharge 

Senior matron, 
Emergency 
Department 

5. 

For the senior matron and ED consultants for the Emergency 
Department to ensure all staff carry out robust communication and 
timely documentation. 

Senior matron, 
Emergency 
Department 

6.   For the Senior Matron for the Emergency Department to discuss a 

plan for ensuring huddles take place overnight in the Emergency 
Department with Paediatric Emergency to ensure robust 
communication between the nursing and medical teams 

Senior matron, 
Emergency 
Department 

30/05/2025 

30/05/2025 

30/05/2025 

Copy of the 
training plan 

Copy of the 
training plan 

Copy of the 
training plan 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7. 

To discuss the Paediatric Asthma Wheeze Guidelines during team 
days 
. 

Senior matron, 
Emergency 
Department 

8.  Education in the doctor’s induction program on TTA medications  

9.  All new doctors starting in the Emergency Department, there is 
now a teaching session during induction focusing on Paediatrics 
and regular sessions ongoing to maintain this education to include 
individualised specific safety netting depending on clinical 
symptoms.  

Relevant Recommendation – Pharmacy Provision   
10 

To ensure pharmacy provision in the Emergency Department 
through the implementation of plans for a dedicated ED 
Pharmacist. 

11.  To ensure sufficient supply of medication in the adult TTA stock 

cupboard in the Emergency Department and to include medication 
stock responsibilities in job planning. 

Relevant Recommendation – Pharmacy Digital Solutions 
12.  As part of the working group there will be discussions about how 

deteriorating young people (between aged 16–18-year-old) can be 
captured by using PEWS or NEWS 
Relevant Recommendation – Shared Learning  
13.  To formalise the process of shared learning of emergency 

department safety events between Royal Free, Barnet and North 
Middlesex Hospital sites through the regular meetings of the 

Emergency 
Department 
Governance Lead  
Emergency 
Department 
Governance Lead 

Divisional clinical 
director for acute 
medicine, emergency 
and elderly care 
Divisional clinical 
director for acute 
medicine, emergency 
and elderly care 

The PEWS 
Implementation 
Working Group 

Divisional clinical 
director for acute 
medicine, emergency 
and elderly care 

30/05/2025 

Completed/ 
Ongoing 

Completed 

Copy of the 
training plan 

Copy of the 
training plan 

Copy of the 
training plan 

30/05/2025 

Copy of the 
business case  

30/05/2025 

Copy of the 
training plan 

30/05/2025 

30/05/2025 

Copy of the 
meeting 
minutes  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 14. 

Leadership of the ED services (senior matrons and governance 
leads). 
In addition to these measures, this case has been shared on 
multiple occasions during Paediatric and ED Mortality and 
Morbidity (M&M) meetings for ongoing and shared learning 

Relevant Recommendation – other   
15.  Following this safety event, all paediatric patients with persistent 
abnormal vital signs at the point of discharge, must be referred to 
Paediatrics prior to discharge, the guideline has been updated and 
shared to reflect this requirement 

16.  Paediatric consultants cover in place consistently from 09:00 to 

23:00 (Monday to Friday)  

Divisional clinical 
director for acute 
medicine, emergency 
and elderly care 

Clinical Director for 
Childrens' Services 
Royal Free London 
(Barnet, Chase Farm & 
Royal Free North 
MIddlesex) 
Clinical Director for 
Childrens' Services 
Royal Free London 
(Barnet, Chase Farm & 
Royal Free) 

Completed 

Completed 

Completed/ 
Ongoing  

 
 
 
 
 
 
 
 
 
 
 
 We will be sending a copy of this letter to North Central London Integrated Care Board.  

If you would like any further information about any part of this letter, please do not hesitate to 
contact us.  

Yours sincerely,  

Director of Nursing,   
Royal Free Hospital         
London Group NHS Trust 

Medical Director 
Royal  Free  Hospital  Royal  Free 
Royal  Free  London  Group  NHS  Trust