Finlay Roberts

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

15th July 2025 

Dear Dr Hassell, 

We are saddened to read of the death of Finlay Roberts from a condition which may have been 
treated if identified.  

The standards that RCEM published in 2024 in our Guidelines for the provision of Emergency 
Services include that “Emergency Departments must use a specific paediatric early warning score 
and ensure that appropriate triggers and actions are in place.” All Paediatric early warning scores 
dictate how often observations should be checked depending on the age of the child and initial 
observations.  

RCEM regularly conducts national audits of provision of care in children. In 2019 we looked at the 
assessment and management of febrile children and found that 97% of Emergency Departments 
were using a specific paediatric early warning score, which had improved since 2015.  

RCEM is involved in the design and piloting of a revised paediatric early warning score specifically 
intended for Emergency Departments. 

As a college we recognise that crowding and understaffing often have a role to play in poor care and 
continue to advocate for better staffing and resources. In conjunction with the Royal College of 
Nursing we have produced minimum standards of nursing for Emergency Departments, and 
recognise the issues in providing these.  

We are also involved in the revision of the Facing for Future standards for paediatric care in 
Emergency Departments 

With kind regards, 

Dr 
RCEM Quality in Emergency Care Committee Co-Chair

Royal College of Nursing 
20 Cavendish Square 
London 
W1G 0RN 

General Secretary & Chief Executive  

Telephone   
Email          

Executive Assistant: 
Telephone   
Email  

; coroners@camden.gov.uk  

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

Sent by email: 

31 July 2025 

Dear Mr Hassell,  

Re: RCN Response to the Inquest touching the death of Finlay Joshua Roberts 
Regulation 28 - Prevention of Future Deaths Report. 

Thank you for sharing your report with us regarding the tragic and untimely passing of 
Finlay Joshua Roberts. I was very sorry to hear of Finlay’s death. We respond to your 
Prevention of Future Deaths (PFD) Report dated 20 June 2024. 

With  a  membership  of  over  half  a  million  registered  nurses,  midwives,  health  visitors, 
nursing  students,  nursing  support  workers,  nursing  associates  and  nurse  cadets,  the 
Royal  College  of  Nursing  (RCN)  is  the  voice  of  nursing  across  the  UK  and  the  largest 
professional union of nursing staff in the world.   

RCN  members  work  in  various  hospital  and  community  settings  in  the  NHS  and  the 
independent  sector.  The  RCN  promotes  patient  and  nursing  interests  on  numerous 
issues  by  working  closely  with  the  Government, the  UK  parliaments and other national 
and  worldwide  political  institutions,  trade  unions,  professional  bodies,  and  voluntary 
organisations.  

Not  all  registered  nurses,  midwives,  health  visitors,  nursing  students,  nursing  support 
workers and nurse cadets are members of the RCN.  The Nursing and Midwifery Council 
(NMC)  is  the  independent  regulator  for  nurses  and  midwives  in  the  UK  and  nursing 
associates in England.  The NMC’s register shows who can practise as a nurse or midwife 
in the UK or as a nursing associate in England.  

We are not the regulator for nurses in the UK, nor do we have any control over individual 
nursing  practice  in  individual  workplaces;  therefore,  we  have  no  remit  to  address  the 
concerns  you  have  noted  in  respect  of  this  death.  However,  the  RCN  offers  a  suite  of 
learning resources to support nurses, students, nursing support workers, midwives, and 
health care professionals at all  stages of their  careers. We provide expert-led, quality-
assured,  evidence-based  education  for  continuing  professional  development  CPD  and 
learning on a range of topics and subjects.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
      
 It is not for the RCN to comment on the performance of any individual nurse or nursing 
associate. 
We note the Matters of Concern set out in Prevention of Future Deaths as:  

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. 

We have considered your report carefully. Of the matters noted, we believe one is of 
particular note to the Royal College of Nursing.  

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. 

From the information provided we do not know how many observations (if any) Finaly had 
during his stay in the Emergency Department. Observations are important as part of a 
holistic assessment of children. There are many reasons why observations might not be 
obtainable, however the RCN recognises that challenges are significantly exacerbated 
by gaps in clinical nursing rotas resulting in understaffed departments. The RCN cannot 
comment on the specific factors in this emergency department that may have 
contributed to Finlay’s tragic passing.   

Beyond  calls  and  actions  at  the  individual  level,  such  as  awareness,  education  and 
training,  broader  systemic  and  cultural  considerations  are  necessary.  Staffing  levels, 
skill  mix  within  the  team,  clinical  governance,  policy,  procedures,  escalation  plans, 
raising concerns, management of deteriorating patients, patient safety reviews, and how 
organisational  learning  is  undertaken  following  mortality  and  morbidity  reviews  must 
not be overlooked.   

The RCN has been collaborating with NHS England and the Royal College of Paediatric 
and Child Health (RCPCH) to develop a single national paediatric early warning system 
(PEWS) for England since 2018 and are supportive of equivalent processes across the 
UK. The RCN has produced supportive educational material to support the role out of 
this initiative System wide Paediatric Observations Tracking Programme. This work is 
aimed for implementation across the four-nations in the UK.  

The RCN is also collaborating with the RCPCH in the revision of the emergency care 
standards for children and young people which will specify that observations are part of 
holistic care and repetition is dependent on the child’s well-being, alongside clarification 
around frequency of observations. 

 
 
 
 
 
 
 
 
 
 
 
 
 According  to  the  NMC  annual  report,  27,168  people  left  the  register  in  the  last  year, 
slightly fewer than the previous year. Of those who left, 20.3% (5,508) were nursing and 
midwifery professionals who left within the first 10 years of starting their careers. This 
percentage  has  increased  for  the  third  consecutive  year,  up  from  18.8%  in  2020-2021. 
Additionally,  49%  of  those  who  completed  the  leavers  survey  indicated  leaving  their 
profession earlier than expected. Nursing staffing levels impact patient safety. We can’t 
improve  one  without  improving  the  other.  Our  Nursing  Workforce  Standards  are  a 
roadmap for designing a workforce that can offer patients high-quality care. 

Many  nurses  are  caring  for  unsafe  numbers  of  patients  and  facing  overwhelming 
pressure  and burnout.  A  2024  report by the  University of  Bath  identifies  psychological 
stress, workload, staff shortages, and pay as the top reasons for staff leaving the NHS. 
Rising  burnout  symptoms,  declining  job  satisfaction,  and  low  confidence  in  improving 
working  conditions  were  also  observed.  Additionally,  the  proportion  of  NHS  nurses 
recommending working for the NHS to others has significantly decreased, highlighting 
significant retention concerns.  The right nursing staff with the right skills must be in the 
right place at the right time to deliver the care children and young people require. 

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

Yours sincerely  

General Secretary & Chief Executive

Sent by email to:  

Dear Mr. Hassell,  

Coroner ME Hassell  
Senior Coroner  
Inner North London  

18 August 2025 

Re: RCPCH Response to the Inquest Touching the Death of Finlay Joshua Roberts 
A Regulation 28 Report – Action to Prevent Future Deaths 

Thank you for sharing your report with us regarding the tragic and untimely passing of Finlay 
Joshua Roberts. I was very sorry to hear of Finlay’s death.  

We have considered your report carefully and note your concerns regarding a lack of nursing 
observations. You have also noted that a lack of paediatric nursing observations was the 
subject of another of your recent PFD reports following the death of Billie Wicks, to which 
RCPCH provided a comprehensive response in May 2025.  

As we noted then, observations are important but are part of a holistic assessment of 
children. There are lots of reasons why observations might not be obtained, and  RCPCH 
recognises that challenges in adequately staffing emergency departments may be one 
reason. In 2024, RCPCH carried out work to better understand where rota gaps most 
prominently impact on paediatric staffing, and we continue to advocate at a local and 
national level for an active reduction in these gaps.  

The RCPCH Facing the Future Standards for Emergency Care 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 these standards, to be published later in 2025. The revised 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. This update has 
been led by an Intercollegiate Committee for Emergency Care, including representation from 
the Royal College of Nursing.  

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

Yours sincerely 

Professor 
RCPCH President

Private and Confidential 
HM Coroner ME Hassell 
Senior Coroner 
Inner North London 
St. Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

15th August 2025 

Dr 

Chief Medical Officer  
Medical Directorate 
Whittington Health  
Jenner Building 
Magdala Avenue 
London N19 5NF 

Tel: 

Email: 

www.whittington.nhs.uk   

RE: Regulation 28 – Response to Prevention of Future Deaths Report – Finlay Joshua Roberts 

 Dear Senior Coroner Hassell, 

Thank you for your Prevention of Future Deaths (PFD) report dated 20 June 2025 concerning the 
tragic death of Finlay Joshua Roberts. First and foremost, we extend our deepest condolences to 
Finlay’s family. We fully recognise the seriousness of the matters you have raised and are committed 
to sustained, systemic improvements to ensure that lessons are learned and embedded into our 
practice.  

Below is our response to the concerns raised, along with the actions taken and those in progress to 
reduce the risk of similar future incidents. 

1. Failure to Carry Out Serial Nursing Observations 

We accept the coroner's finding that there was an omission in not conducting serial complete sets of 
nursing observations. Since Finlay’s death, a number of interventions have been implemented. 

Actions Taken: 

•  Training & Induction Enhancements: 

o  All new nurses now receive training on vital signs monitoring and escalation during 
induction and in-house triage training. This ensures that all new starters have a 
foundational understanding of the importance of recording and escalating abnormal 
observations from the outset. All clinical staff are also required to familiarise 
themselves with the department’s common presentation policies during their 
induction. 

Whittington Health NHS Trust 

Chair: 

          Chief Executive: 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 
 
 
  
 
 o  All adult nurses deployed to work in Paediatric 

Emergency Department are provided with local induction to the unit as set out in 
the Trusts induction policy.  

o 

In addition, practice development support has been introduced in Paediatric 
Emergency Department, with a focused priority on vital signs monitoring and 
escalation training for the entire Emergency Department team to ensure that they 
have the same foundation.  

o  At triage a complete set of vital signs appropriate to their clinical presentation is 

required for every child presenting to the department with a medical complaint. This 
standard has been reinforced through the Emergency Department Triage Training 
Study Day, which all triage nurses attend. These triage observations will be as 
recommended by the Royal College of Emergency Medicine (RCEM) 

•  Monthly and Manual Audits: 

o  Monthly audits of compliance with vital sign observations have been instituted with 
the support of the Information Requests Team, with outcomes reviewed by the 
paediatric emergency department senior team. These will be used to identify 
ongoing training needs and support continuous improvement with feedback to the 
team. 

o  Senior nurses perform random manual audits of observation charts four times per 
month. The data is feedback to the team through email, message of the month and 
on an individual basis.  

o  The vital signs observations audits will be presented at the division’s quality meeting 

on a quarterly basis. The next Meeting is scheduled August 2025.  

• 

Simulation Training with PEWS: 

o  Paediatric Early Warning Scores (PEWS) have been embedded into multidisciplinary 
simulation training. These simulations take place on alternative Thursdays, including 
the children’s and young people department which allows collaborative learning for 
acute Paediatrics.  

•  Clinical Standards Embedded: 

o  A complete set of vital signs appropriate to the clinical presentation is explicitly 

required at triage for all children presenting with medical complaints, and those with 
abnormal observations will be escalated according to the score requirement in 
national guidance as stipulated by the national paediatric early warning score 
(PEWS). 

Whittington Health NHS Trust 

Chair: 

         Chief Executive: 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 
 o  The timing of a repeat set of observations follows the 

PEWS algorithm which supports escalation level including a communication and 
response framework.  

o  This requirement is reinforced in training days attended by all nurses involved in 

triage, handover briefings, and via monthly staff communications. 

o  Local records are held on staff training/, competences, (PEWS, triage) 

•  Electronic Monitoring Enhancements: 

o  Four additional electronic devices have been deployed in the department to 

facilitate real-time recording and review of vital signs. Each Nursing staff member 
has access to an electronic device for inputting Vital signs.  

o  The Nurse in Charge (NIC) workstation has been upgraded to a dual-screen system, 

enabling more effective live monitoring of deteriorating patients. 

o  The digital medical record in PED has been updated and all current staff who use it 

have been notified. proforma used for assessment 

2. Medical Staff Not Recognising the Lack of Observations 

We acknowledge that staff failed to identify that vital observations were incomplete and not 
repeated at the time of Finlay’s discharge. In response: 

o  The emergency Paediatric Clerking proforma now requires doctors to specify the 

frequency that observations should be done. 

o  The ED paediatric discharge checklist now requires that there is a review of patient’s 
vital signs prior to discharge. This has been implemented since Finlay’s death and its 
use will be audited regularly. 

o  The discharge checklist will be disseminated at ED and surgical induction in August 

and paediatric induction in September and at all future medical inductions 
thereafter. 

o  Audits will be conducted and will be presented at the division’s quality meeting on a 

quarterly basis. 

Whittington Health NHS Trust 

Chair: 

          Chief Executive: 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 
 
 
 3. Systemic Concerns Around Observation Practice 

You raised concerns that the issue of missed observations may not be confined to Whittington 
Health NHS Trust. 

Actions Taken and Ongoing: 

•  Collaboration and Benchmarking: 

o  We are actively participating in a regional benchmarking initiative led by the North 
Thames Paediatric Network to examine standards of practice, share learning, and 
identify system-wide improvement opportunities. 

•  Environmental and Staffing Enhancements: 

o  The Paediatric Emergency Department currently has two recent vacancies. The 

department maintained 100% filled vacancies prior to this.  

o  The lead Nurse for PED has focused on retention and recruitment to ensure nursing 
vacancies are mitigated with support from general ED nurses who have completed 
the Paediatric ED rotation and RCEM Paediatric competencies.  

o  Staffing levels in the Paediatric Emergency department have been reviewed and 

aligned with SNCT (safer nursing care tool data), and professional judgement based 
on staff feedback. This review resulted in additional nursing staff. The staffing levels 
will continue to be reviewed and reported to the Board on a six monthly basis.  

o  We have introduced the allocation of cubicles where nurses are assigned 

responsibility for specific cubicles and key assessments i.e. Triage and patient 
cohorts to ensure ownership and continuity of care. 

o  Triage responsibilities have been restricted to nurses with a minimum of one year of 
paediatric emergency experience and completion of the RCEM triage competency 
workbook. All triage nurses undergo Manchester Triage training and competency 
training before they can autonomously assess children on arrival.  

• 

Safe Staffing Governance: 

o  The Emergency Department Nurse in Charge checklist has been updated to align 
with RCEM guidance on paediatric emergency staffing and now explicitly includes 
paediatric-specific checks.  

4. Timetable for Outstanding and Continuing Actions 

Whittington Health NHS Trust 

Chair: 

          Chief Executive: 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 
 There are no outstanding actions.  

However, for continuing actions there will be:  

o  Ongoing monitoring of compliance by the senior nursing and medical team with 
oversight from the paediatric and emergency department clinical governance 
committees reporting into the Patient Safety Group on a 3 monthly basis. Patient 
Safety Group reports to Trust Board via the Quality Governance and Quality 
Assurance Committees. 

o  Ongoing training and induction for all staff in regard to the importance of complete 
observations and their escalation. This training will also be part of all simulation 
training in PED 

o  Continued use of the ED paediatric discharge checklist.  

o  There will also be ongoing participation in the regional benchmarking initiative led 
by the North Thames Paediatric Network to examine standards of practice, share 
learning, and identify system-wide improvement opportunities.  

o  Continued monitoring of staffing levels and equipment to ensure safety is 

maintained 

Conclusion 

We remain deeply saddened by Finlay’s death and are committed to ensuring this loss leads to 
lasting change. We are grateful for your findings and for the opportunity to implement and share 
learning that may help prevent similar deaths in future. 

Please let us know if any further information is required or if clarification of any part of this response 
would be helpful. 

Yours sincerely, 

Dr 
Chief Medical Officer  

MBBS BSc PhD FRCP (GMC 3360145) 

Whittington Health NHS Trust 

Chair: 

          Chief Executive: 

Helping local people live longer healthier lives