Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0122, written 4 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2026 |
|---|---|
| Reference | 2026-0122 |
| Deceased | Viviana-Ray Butnaru |
| Coroner | Jyoti Gill |
| Coroner area | Essex |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid and South Essex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of Basildon Hospital (Mid & South Essex NHS Trust) 2. The Royal College of Paediatrics and Child Health 1 CORONER I am Jyoti Gill, assistant coroner, for the coroner area of Essex 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 4 November 2024 an investigation into the death of Viviana-Ray Winnie Elsie Wendy Butnaru, age 14 months was commenced. The investigation concluded at the end of the inquest on 4 February 2026. The conclusion of the inquest was a narrative conclusion which stated that Viviana-Ray Winnie Elsie Wendy Butnaru died of complications arising from the onset of myocarditis caused by Parvovirus contributed to by a background of bronchiolitis and bronchopneumonia. 4 CIRCUMSTANCES OF THE DEATH Police referral. Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department (Basildon Hospital) at 23:18 on 24 October 2024. Chest X rays were taken which identified cardiomegaly, but these were not officially reported until 29 October 2024 (after Viviana-Ray had passed away). Initially an Emergency Department Registrar had suspected that the chest X ray showed an enlarged heart. This information was not recorded anywhere but verbally handed over by the ED Registrar to the Paediatric Registrar. The Paediatric Registrar in evidence did not recall this verbal handover. The Paediatric Registrar had not identified an enlarged heart upon her review of the chest X ray. Blood gases were taken which showed Viviana-Ray to be in metabolic acidosis, but these were not reviewed by the Paediatric Registrar when the results were initially made available during her shift. The Associate Director of Nursing for Paediatrics at Mid & South Essex NHS Trust stated that the Children’s Early Warning Tool (“CEWT”) Red score was not escalated in accordance with trust policy. No blood pressure readings were ever taken of Viviana- Ray, and it was stated that all children presenting to the Paediatric Emergency Department should be reviewed using the PIER Sepsis Tool during triage which was not completed for Viviana-Ray. The Trust also stated that when Viviana-Ray had an Amber score with two triggers which requires a review by the Nurse in Charge (NIC) and a Paediatric Registrar within 20 minutes, that this was also not complied with. Aside from the initial observation, no other observations or nursing documentation was completed during Viviana-Ray’s attendance at the Paediatric Emergency Department. Whilst a review took place at 10:15 am on 25 October 2024 by the Paediatric Consultant, no further review appears to have taken place until 16:00 later that day. The Paediatric Consultant stated that clinically Viviana-Ray looked like she was improving despite Viviana-Ray’s blood gas levels showing she was in metabolic acidosis. A repeat blood gas was not performed as the Paediatric Consultant attributed any decline in these results to be associated with her bronchiolitis and suspected sepsis and no other underlying cause for the metabolic acidosis was explored. The Paediatric Consultant had not noticed an enlarged heart on Viviana-Ray’s chest X ray and stated that it was normal for children to often have slightly larger hearts on X rays due to the angles in which these are taken. The Paediatric Consultant stated that staff had not made her aware of any further concerns during the remainder of her shift except until 4 pm when a nurse notified her that Viviana-Ray was working harder with her breathing. During the inquest another Paediatric Consultant giving expert evidence (and involved in the Patient Safety Incident Report) stated that she found that there were features of mild to possibly moderate cardiomegaly (enlarged heart) on both chest X-rays. The Paediatric Consultant stated that it would be difficult to definitively determine whether the missed identification of cardiomegaly would have led to a cardiac arrest, but that earlier detection and intervention, including additional investigations and consultation with a tertiary Paediatric Cardiology centre, might have provided further insights and possibly informed management decisions. The Associate Director of Nursing for Paediatrics stated that based on Viviana-Ray’s physiological parameters and CEWT score, earlier medical reviews would have been beneficial considering her clinical trajectory. Viviana-Ray’s breathing was worsening, and her condition began to deteriorate around 9 pm on 25 October 2024 and it was at this time when it was first suspected that Viviana- Ray was experiencing heart failure. Arrangements were made for urgent intubation. A crash call was put out for the anaesthetic team. Viviana-Ray had lost her pulse, and pulseless electrical activity was confirmed at 21:46. Viviana-Ray was intubated and Cardiopulmonary Resuscitation continued following the Non-shockable Pathway. Viviana-Ray had CPR for 51 minutes but was sadly declared deceased at 22:37 at Basildon Hospital. The cause of death is myocarditis caused by the Parvovirus, contributed to by a background of bronchiolitis and bronchopneumonia. Expert evidence in this case noted that by the time the heart failure was clinically obvious there would not have been an opportunity to reverse the situation as Viviana- Ray arrested shortly afterwards. The expert went on to say that Parvovirus was the likely cause of the myocarditis and that Acute Fulminant Myocarditis is characterised by the rapid onset of severe heart failure and cardiogenic shock, requiring advanced pharmacological or mechanical circulatory support. The expert also stated that there has been a recent surge in Parvovirus amongst children following the Covid pandemic. It was stated that diagnosing this remains challenging and that it would be helpful for paediatricians to have guidance on how to identify such cases. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – National Concerns: (1) There appears to be a lack of local or national guidelines assisting those assessing patients in an accident and emergency and paediatric environment to assess the correct pathway for identifying and investigating those who may present with heart related issues such as myocarditis. (2) Raising awareness of the existence of Parvovirus considering the surge of this virus in children post the Covid 19 pandemic. Local Concerns: (3) Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later. (4) Underlying causes for metabolic acidosis were not fully explored. Greater awareness of the difference between metabolic and respiratory acidosis is required. (5) Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th April 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (Miss Viviana-Ray Butnaru’s Mother) The Care Quality Commission NHS England (Expert Witness) I have also sent it to find it useful or of interest. of Gadsby Wicks (Family Solicitor) who may I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 DATED: 4th March 2026 Assistant Coroner for Essex
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
FAO Ms Jyoti Gill His Majesty’s Assistant Coroner SEAX Court Chelmsford Essex Dear Madam, Basildon Hospital Nethermayne Basildon Essex SS16 5NL 28 April 2026 Inquest touching on the death of Miss Viviana-Ray Butnaru- Regulation 28 Report I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 4 March 2026 in respect of the above. The report was issued to Mid and South Essex NHS Foundation Trust (MSEFT) and The Royal College of Paediatrics and Child Health following the Inquest hearing which concluded on 4 February 2026. The ‘local concerns’ attributed to MSEFT as noted within the Regulation 28 Report have been carefully reviewed by senior clinical colleagues, I hope that this response addresses your concerns and provides both yourself and Viviana-Ray’s family the necessary assurance that we have taken robust action to learn from Viviana-Ray’s sad death. Local Concerns: (3) Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later. Response: The Director of Nursing for the Clinical Division of Clinical & Support Services has undertaken a review of Viviana-Ray’s imaging timeline. As you are aware Viviana-Ray had a chest x-ray examination undertaken on 24 October 2024 at 23:56 hours, whilst she was in Basildon Emergency Department (ED). Plain film examination images are initially clinically reviewed and interpreted by a member of the ED team to guide onward care for patients, and in addition they are formally reported on by the Radiology Department. The chest x-ray from 24 October 2024 was formally reported by a Paediatric Radiologist on 29 October 2024 at 15:09 hours. This reporting timeframe totalled 111.5 hours. Similarly, the chest x-ray examination Vivana-Ray had on 25 October 2024 at 20:14 hours was formally reported by a Paediatric Radiologist on 29 October 2024 at 15:39 hours. This reporting timeframe totalled 86.5 hours. I enclose a copy of the Trust's Radiology Report Turnaround, Escalation and Risk Stratification of Backlog Policy (MSEPO-24003), which advises the maximum time from exam to report for ED plain film x-rays, is 72 hours. The Trust recognises the turnaround reporting timeframes detailed for Viviana-Ray’s x-rays deviate from our policy and non- compliance with this Key Performance Indicator (KPI) has been recognised and is under review and management via the Trust’s risk register, under reference: 1086. At the time of Viviana-Ray’s admission, the Trust had a process in place whereby the Paediatric Team could escalate a clinical concern to the designated Duty Radiologist from 09:00 hours to 20:30, 7 days a week. The escalation is a specific request to expedite an imaging report. Regrettably, this was not done in Viviana-Ray’s case, and our conclusion is that the process was not well known by staff at that time. The Radiology Department identified that guidance for clinical teams on how to expedite an imaging report due to clinical concern was not documented in Trust radiology policies and procedures. As such, the Director of Nursing has confirmed that a review of the Trust’s policy, Guide for making the best use of a Radiology Department (MSEGL23134) will be completed by 1 June 2026 to ensure an updated version is formalised to include this guidance going forward. The Trust will be able to share a copy of this updated policy with you in due course if it is of assistance. As a result of these guideline changes, targeted sharing of the changes will be undertaken with the Paediatric teams across our sites within MSEFT, alongside the updated guideline being available on the Trust's intranet page, which is accessible for all staff. (4) Underlying causes for metabolic acidosis were not fully explored. Greater awareness of the difference between metabolic and respiratory acidosis is required. Response: Both the Clinical Lead for Paediatrics and the Associate Director of Nursing for Paediatrics have confirmed the service identified these issues during the initial review of the incident, and a specific action was implemented to address concerns relating to blood gas interpretation and documentation, particularly where results were inconsistent with the working diagnosis. Targeted bite-size education sessions focusing on recognising abnormal blood gas results and appropriate escalation were delivered by the Clinical Practice Facilitator (CPF) team across Children’s Emergency Department and inpatient wards. To further support staff in real-time clinical practice, business-card sized blood gas prompts were distributed following the sessions and staff attached these to their lanyards. These prompts are intended to support early recognition of deteriorating trends and prompt timely escalation. Viviana-Ray’s case has been discussed at various trust forums, to share learning and the associated actions that have been taken. The case was presented at Basildon’s site Mortality and Morbidity (M&M) meeting in March 2026, which is attended by consultants, tier 1 and 2 doctors and clinical nurse facilitators. Her case has also been discussed at the cross-site Grand Round in January 2026, during this meeting the case was discussed with learnings and differential for metabolic acidosis including cardiac and attended by consultants, tier 1 and 2 doctors and Associate Directors of Nursing. A safety bulletin has also been circulated to all staff in February 2026. Further learning has been reinforced through local teaching sessions, supported by multiple delivery methods including verbal teaching, live simulation, and a formal “learning from incidents” bulletin. This multi-modal approach has ensured learning has reached both nursing and medical teams across a range of forums. (5) Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded. The paediatric service recognises that there were gaps in fully documenting nursing observations and escalation actions. In response, Children’s Early Warning Tool (CEWT) refresher training has been delivered to all relevant nursing and support staff, with specific emphasis on clear documentation of escalations made and responses received. CEWT audits on the inpatient wards were initially undertaken on a monthly basis. Due to increasing variability in compliance, audit frequency was escalated to daily audits from September 2025, enabling earlier identification of non-compliance, more timely feedback to clinical teams, and improved real-time assurance of escalation practice. In Children’s ED, daily CEWT audits have been in place since March 2025, providing continuous oversight. Between October 2025 and March 2026, CEWT compliance remained 90 - 100% in Children’s ED, and 85 - 95% on the inpatient wards. Where audits identified variability or reduced compliance, targeted improvement actions were implemented. These included allocation of a named CEWT champion on each shift, senior nurse spot checks, shared learning discussed during safety huddles and real-time feedback provided directly to staff. It is recognised that during periods of high patient volume and acuity, compliance may temporarily dip due to increased clinical pressure. During these periods, mitigations are implemented, including the use of support workers to assist with observations, to maintain safety and oversight. In parallel, the Trust is implementing the National Paediatric Early Warning System (nPEWS) across paediatric services. Robust governance arrangements are in place, including a weekly task-and-finish group to oversee delivery and provide assurance. A comprehensive 12-week education and training programme started on 13 April 2026 for the planned June 2026 go-live, ensuring staff are prepared and supported. nPEWS explicitly incorporates clinical intuition and carer concern into escalation criteria, reinforcing professional judgement alongside physiological observations. The revised charts also introduce a dedicated escalation record, strengthening visibility, accountability, and assurance around escalation and clinical decision-making. In addition, monthly documentation audits continue across both Children’s ED and the inpatient wards. Documentation compliance in Children’s ED remained above 95% between October 2025 and March 2026. On the inpatient wards, compliance ranged between 75% and 95% during the same period. Reduced compliance identified in December 2025 related to illegible handwriting, unsigned amendments, and incomplete nursing documentation. Feedback was provided directly to staff, with reminders regarding documentation standards and their importance for patient safety and medico-legal assurance. Subsequent audits have demonstrated improved compliance, indicating that learning has been embedded. Finally, the nursing teams have reflected deeply on Viviana-Ray’s death, and those directly involved have completed written reflective accounts alongside one-to-one refresher sessions covering the areas identified above. Learning from this case has also been extended to the wider nursing and multidisciplinary team. Meaningful improvements have been made to our practice across all services involved, and the Trust remains fully committed to ongoing learning, reflection, and careful monitoring following this very tragic case. We understand that the Court will share a copy of this reply with Viviana-Ray’s family. If I can assist you further in this case, please do not hesitate to contact me. Yours sincerely Chief Medical Officer Mid and South Essex NHS Foundation Trust Enclosed: i) MSEPO-24003 Radiology Report Turnaround, Escalation and Risk Stratification of Backlog Policy
5 -11 Theobalds Road London WC1X 8SH - Jyoti Gill Assistant Coroner for Essex 20 May 2026 Dear Ms. Gill, Re: RCPCH Response to the Inquest Touching the Death of Viviana-Ray Winnie Elsie Wendy Butnaru – A Regulation 28 Report – Action to Prevent Future Deaths Thank you for sharing your report with us regarding the tragic and untimely passing of Viviana-Ray Winnie Elsie Wendy Butnaru. I was very sorry to hear of Viviana-Ray’s death. We have considered your report carefully. Myocarditis is a very uncommon presentation in children. RCPCH Facing the Future: Standards for Children and Young People in Emergency Care Settings (5th edition, updated October 2025) provide a comprehensive framework for system-level safety in emergency care settings. While these standards do not include condition-specific pathways for rare but serious presentations such as myocarditis, they describe how paediatric care should be delivered to provide a safe and sustainable, high-quality service that meets the health needs of every child and young person. The standards apply to all persons up until the age of 18 and 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 recently completed a comprehensive review, revision and update these standards under the auspices of an intercollegiate committee for emergency care. Several of these standards are relevant to your concerns. In particular, Chapter 4 (Management of the Sick or Injured Child) sets clear expectations that all children attending an emergency department must undergo timely triage within 15 minutes, receive a full set of physiological observations, and be assessed using a paediatric early warning system with clearly defined escalation protocols. Abnormal observations must prompt timely escalation and senior clinical review, with repeat observations performed at defined intervals. These standards directly relate to the issues identified in this case, including failure to escalate CEWT scores, absence of repeat observations, and delayed recognition of clinical deterioration. In addition to this, RCPCH are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS). PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. 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. Chapter 12 (Information Systems and Quality Care Indicators) sets expectations for clear, contemporaneous documentation, structured communication and handover processes, and timely access to diagnostic reporting systems. These standards address the deficiencies identified in documentation, communication of radiological findings, and delayed reporting of chest X-rays. In addition, Chapter 3 (Workforce and Training) requires access to consultant-level paediatric expertise and appropriately trained staff capable of recognising serious illness, which is relevant to the delayed recognition of cardiac pathology and clinical deterioration. With regard to other matters of concern specific to children that you raise: • Parvovirus awareness. We are not aware of any change in the overall prevalence of this common virus in the population • Chest X ray reporting. This lies outside of our control but we recognise that there is often some delay between images being taken in the context of an emergency and a formal report being issued. All clinicians have some training in interpreting chest x rays. • Metabolic acidosis is a non-specific feature of many acute presentations in children. Respiratory acidosis is very uncommon in children Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Viviana-Ray’s family. Yours sincerely RCPCH President
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