Ethan Hanson

George Eliot Hospital NHS Trust 
College Street 
Nuneaton 
Warwickshire 
CV10 7DJ 

21 May 2026 

PRIVATE & CONFIDENTIAL 

Ms L Lee 
HM Assistant Coroner 
Warwickshire Justice Centre 
Newbold Terrace 
Leamington Spa 
CV32 4EL 

Dear Ms Lee 

RE: REGULATION 28 REPORT – ETHAN HANSON 

Further to your report which the Trust received on the 30 March 2026, in accordance 
with  paragraph  7,  Schedule  5  of  the  Coroner’s  and  Justice  Act  2009  and  the 
regulations 28 and 29 of the Coroner’s (investigations) Regulations 2013, I offer the 
following response:-   

Following  the  Coroner’s  inquest  on  Monday  16  April  2026,  regarding  the  death  of 
Ethan Hanson (EH).  The Trust would like to formally acknowledge the findings of the 
coroner and recognises its responsibilities in conjunction with the actions as detailed 
in the Regulation 28, Prevention of Future Deaths notice. 

In response to the Regulation 28 notice, the Trust took immediate action by convening 
a multidisciplinary meeting on Wednesday 29 April 2026. The meeting was chaired by 
the Chief Nursing Officer and attended by both internal and external partners, including 
representation from General Practitioners and the Integrated Care Board (ICB). 

The purpose of the meeting was to undertake a collective, multidisciplinary review to 
understand how future care delivery could be strengthened. The discussion focused 
on ensuring that all opportunities are consistently identified and acted upon, with the 
aim of developing a more robust and integrated care pathway that mitigates the risk 
of similar incidents occurring in the future. 

The actions and outcomes of the meeting form part of the Trust’s response below. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  Absence Of Computerised Mandatory Field Safeguards 

There is no electronic system with mandatory fields or hard‑stops to prevent incorrect 
or incomplete recording of observations or pain scores. A transposition error between 
oxygen saturation and temperature occurred. The absence of automated safeguards 
requiring complete and accurate observations before pathway selection or discharge 
creates a risk that clinically significant information may be overlooked. Although there 
is an intention to develop such a system, it is not currently in place. 

Trusts Response 

The  Trust  recognises  the  concerns  raised  regarding  the  absence  of  an  electronic 
observation  system  incorporating  mandatory  fields  and  automated  safeguards  to 
prevent  incomplete  or  inaccurate  documentation.  The  identified  transposition  error 
between oxygen saturation and temperature illustrates the inherent risks associated 
with  reliance  on  manual  processes  and  underscores  the  need  to  strengthen  digital 
controls to better support clinical decision-making and patient safety. 

An immediate mitigating action was implemented shortly after Ethan’s death to reduce 
the risk of transcription errors while observations remain paper-based. This requires 
all paediatric observations to be repeated prior to discharge from the department, with 
compliance monitored through routine audit processes. 

In  addition,  all  children  triaged  as  ‘yellow’  or  above  under  the  Manchester  Triage 
System  are  reviewed with  a  Registrar or Consultant.  The  ‘yellow’ category denotes 
patients with significant conditions that are not immediately life-threatening but have 
the  potential  to  deteriorate;  as  such,  the  target  is  for  these  patients  to  be  clinically 
assessed within 60 minutes 

In  terms  of  the  future  electronic  system,  the  Chief  Digital  Officer  has  offered  the 
following response: 

The  Trust  is  currently  in  the  implementation  phase  of  its  Electronic  Patient  Record 
(EPR)  programme.  As  part  of  this  work,  the  Trust  is  reviewing  the  critical  delivery 
timeline  to  reflect  issues  identified  within  the  programme  to  date  and  is  therefore 
unable  to  confirm  a  specific  go-live  date  at  this  stage,  although  implementation  is 
currently anticipated in August 2027. The programme is well underway, with funding 
clearly  identified  within  the  Trust’s  financial  plans,  and  the  Trust  remains  fully 
committed  to  successful delivery across  both  George  Eliot  Hospital NHS  Trust  and 
South Warwickshire University NHS Foundation Trust. 

The  Trust  recognises  that  the  implementation  of  the  new  EPR  system  presents  a 
significant opportunity to  improve  the  reliability  and  safety of  clinical  documentation 
and  workflow  processes.  Although  the  detailed  system  design  remains  under 
development, the intention is that the EPR will include enhanced validation processes, 
structured  documentation,  and  clinical  safety  functionality  to  reduce  the  risk  of 
incomplete or incorrect observations being recorded or overlooked. This includes  

 
 
 
 
 
 
 
 
 
 
 
 consideration  of  mechanisms  such  as  mandatory  fields,  automated  prompts, 
escalation  triggers,  and  decision-support  safeguards  to  support  clinicians  prior  to 
pathway selection or discharge decisions. We can confirm that the new EPR system 
will  flag  any  critical  or  unusual  observations  and  will  not  allow  transcriptions  of 
observations that could not be possible such as oxygen saturations of 140.   

Until the EPR system is fully implemented, the Trust will continue to reinforce existing 
governance arrangements, staff training, and clinical oversight processes to minimise 
the  risk  of  similar  errors  occurring  and  to  ensure  that  observations  and  clinical 
assessments are reviewed appropriately as part of safe patient care. Additionally, the 
Trust will seek to implement PEWS documentation within the current electronic Patient 
Track  for  use  in  the  Children’s  Assessment  Unit  (CAU)  as  an  interim  measure  to 
strengthen the recording, visibility, and escalation of paediatric observations 

2.  Pathway Design Not Fully Aligned With National GIRFT Guidance 

The Trust is developing a triage model for paediatric abdominal pain. Evidence heard 
at inquest showed that the pathway options do not mirror the structure or escalation 
principles contained in the national GIRFT guidance for paediatric abdominal pain and 
appendicitis. This carries a risk that children with time‑critical surgical conditions may 
not be escalated promptly or placed on an appropriate pathway. 

Trust Response 

The Trust recognises that the current triage model for paediatric abdominal pain does 
not  fully  align  with  national  GIRFT  guidance,  creating  a  potential  risk  to  timely 
escalation of children with serious surgical conditions. In response, immediate actions 
have  been  taken  to  embed  the  GIRFT  pathway  into  practice,  alongside  targeted 
education,  simulation  training,  and  a  formal  review  to  update  the  Trust’s  Standard 
Operating Procedure and ensure full compliance. These actions include:  

•  The  Trust  is  ensuring  that  all  staff  are  following  the  GIRFT  Paediatric  Acute 
Abdominal  Pain  &  Appendicectomy  Best  Practice  Pathway  Guidance  (June 
2022).     

•  The pathway has been shared with all the clinical staff within the Emergency 
and  Paediatric  Department  to  ensure  all  staff  are  aware  of  the  expected 
approach and to support a more consistent practice.   

•  The Paediatric Lead delivered a teaching session on the 13 March 2026 to the 
Paediatric Team focusing on acute abdominal pain, using this case to highlight 
key learning points.  The importance of following the pathway was reinforced 
again in the clinical huddle afterwards. This teaching session is being repeated 
on the 22 May 2026. 

•  The  learning  from  this  case  is  being  built  into  a  simulation  programme.  The 
upcoming CAU simulation sessions will involve a wider multi-disciplinary group 
and  will  include  scenarios  around  abdominal  pain,  including  neurodivergent 
children, to support better recognition, communication, and escalation. These 
sessions are held monthly. 

•  The GIRFT guidance (paediatric acute abdominal pain) along with the current 
Trust process, is going to be reviewed to identify any gaps and actions needed  

 
 
 
 
 
 
 to ensure compliance and then a new Standard Operating Procedure (SOP) will be 
compiled to align with GIRFT.  This will be completed by the end of June 2026.  

3.  GIRFT Guidance Lacks Practical Mechanisms For Assessing 

Neurodivergent Children And Parents  

The GIRFT guidance recognises that neurodivergent children may be more difficult to 
assess  or  diagnose,  but  it  does  not  provide  practical  mechanisms  for  clinicians  to 
adapt  history‑taking,  pain  assessment  or  communication.  The  guidance  does  not 
consider the risk that a neurodivergent parent may struggle to convey concern, may 
appear reassured  when  they  are frightened, or may  find  questions and  instructions 
confusing or intimidating. The absence of such mechanisms risks misunderstanding 
children’s symptoms and misinterpreting parental reassurance 

Trusts Response 

The  Trust  acknowledges  the  concerns  raised  regarding  the  absence  of  practical 
mechanisms within the GIRFT guidance to support assessment and communication 
with neurodivergent children and their families. However, this matter falls outside the 
Trust’s  direct  remit.  GIRFT  has  been  made  aware  of  these  considerations  through 
receipt  of  the  Coroner’s  Regulation 28  Report to  Prevent  Future  Deaths.  The  Trust 
will, however, ensure full compliance with any enhanced or updated guidance issued 
by GIRFT in response to these findings. 

4.  Local  Processes  Provide  No  Structured  Support  for  Neurodivergent 

Children Or Parents 

Local  assessment  processes  do  not  contain  structured  prompts  or  guidance  for 
recognising  how  neurodivergence  may  affect  symptom  expression  or  parental 
communication. Without a structured approach there is a risk that important clinical 
information  will  not  be  elicited  or  understood,  and  that  apparent  agreement  with  a 
discharge plan may be misinterpreted. 

Trusts Response 

The  Trust  recognises  the  risk  that  the  absence  of  structured  prompts  within  local 
assessment processes may lead to challenges in identifying how neurodivergence can 
influence symptom presentation and communication. In response, the paediatric team 
at GEH has undertaken a review of current processes, guidelines, and training, with 
actions in place to strengthen support for children with neurodiverse conditions and 
learning difficulties, ensuring care is delivered in line with best practice and supports 
improved clinical outcomes 

Actions taken:  

•  The paediatric casualty card is currently being amended to include whether the 
parent/carer  has  any  potential  neurodiverse  implications  which  may  affect 
communication. This has been discussed with the Paediatric Neurodiversity & 
Learning  Disability  Lead  for  South  Warwickshire  NHS  University  Foundation 
Trust  (SWFT),  and  it  was  identified  that  the  question  to  be  placed  on  the 
casualty card should be “does this child have any communication, sensory or 

 
 
 
 
 
 
 behavioural  needs”.   Work  is  now  being 
undertaken to have this included on the casualty card and will be completed by 
the end of May 2026. 

•  Compliance  with  the  Oliver  McGowan  Mandatory  Training  is  required  for  all 
staff. Current compliance within the Clinical Assessment Unit (CAU) stands at 
81%, with full compliance expected by the end of June 2026. 

•  A formal escalation pathway has been developed to support staff in managing 
increased  clinical  curiosity  and 
neurodivergent  patients,  promoting 
consideration  of  atypical  presentations.  Supporting  materials,  including  a 
flowchart and handbook were approved on 21 May 2026 and implementation 
will commence. 

•  Accessible,  easy-to-understand  patient  and  family  information  leaflets  are 
being  developed  to  support  families  in  recognising  and  escalating  concerns. 
These  materials  will  be  co-produced  with  Young  Inspectors,  established 
through  partnership  with  IMPACT  (Warwickshire  County  Council’s  Young 
People’s Forum for SEND), Healthwatch Warwickshire, and Warwick Hospital, 
and will be shared across GEH and SWFT. 

•  The Trust has a Play Specialist in post, providing specialist support to reduce 
anxiety  and  enhance  communication  for  neurodivergent  children  through 
appropriate tools and techniques. 

•  The Trust supports the safe prioritisation and expedited flow of neurodivergent 
children  through  the  Emergency  Department  and  Clinical  Assessment  Unit, 
where clinically appropriate 

•  The Trust is undertaking an evaluation of a pager system to enable families to 
temporarily leave the department while awaiting assessment where the Clinical 
Assessment  Unit  (CAU)  environment  may  be  causing  distress.  A  formal 
demonstration of the system is scheduled for 21 May 2026 to inform feasibility 
and next steps. 

•  The  FLACC  (Face,  Legs,  Activity,  Cry,  Consolability)  behavioural  pain 
assessment tool is being implemented within CAU to support more consistent 
and appropriate pain assessment, with full implementation anticipated by the 
end of June 2026. 

•  The  Trust’s  Communications  Team  is  developing  a  formal  communications 
plan,  in  partnership  with  the  Paediatric  Neurodiversity  &  Learning  Disability 
Lead,  to  increase  awareness  and  utilisation  of  Hospital  Passports  and  “All 
About Me” tools. This will include a public-facing campaign, commencing in July 
2026 and continuing thereafter. 

•  A neurodivergent champion role is being established across GEH and SWFT, 
supported  by  a  dedicated  training  programme.  These  roles  will  act  as 
advocates for neurodivergent patients and their families, with implementation 
scheduled from July 2026. 

•  The professional development portfolios for Advanced Care Practitioners are 
being reviewed and updated to incorporate competencies relating to the care 
of neurodivergent patients, with completion expected by October 2026. 

•  The  Trust  is  scoping  the  development  of  a  dedicated  desensitisation 
environment  within  the  Emergency  Department.  As  part  of  this  work,  the 
Operational and Emergency Department Managers are undertaking a visit to 
St George’s Hospital, Stafford, to review a Cubbie Sensory Pod—an evidence-

 
 
 •  The  Trust  acknowledges 

to 

based  sensory  environment  designed 
reduce  anxiety  and  sensory  overload.  This  will  inform  future  planning  to 
enhance  the  assessment  environment  and  support  improved  communication 
for neurodivergent patients and families 
the  need 

flagging 
neurodivergence. Our approach within our new EPR system is still under final 
discussion, however our overall intention is to apply a reasonable adjustments 
flag  to  the  child’s  digital  record  with  the  consent  of  the  parent,  with 
documentation  focused  on  the  need  for  tailored  communication  support  with 
parents,  rather  than  recording  any  parental  diagnosis  itself.  This  would  align 
better with data minimisation principles while still addressing  and fulfilling the 
required clinical and safety intent. 

for  a  digital  solution 

to 

5.  Critical GP Information Not Carried Forward Into The Hospital 

Assessment 

The GP identified the possibility of appendicitis or another serious underlying cause 
and recorded abnormal observations. The absence of an ambulance conveyance or 
written referral letter meant this information was not transferred to the hospital. As a 
result,  Ethan  entered  a  different  clinical  pathway,  and  the  assessing  clinician  was 
unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the 
implications  of  referral  route  on  triage  and  assessment  in  local  hospitals,  and  that 
critical deterioration indicators can be lost at the point of transfer. 

Trust Response 

The Trust, alongside GP and ICB representatives, acknowledged that the absence of 
access to GP patient records represented a significant gap in the care provided to EH.  

Following  a  multidisciplinary  meeting  held  on  29  April  2026,  it  was  agreed  that  all 
nursing and medical staff within the Emergency Department and Clinical Assessment 
Unit  would be  granted  access  to the  Integrated  Care  Record  System.  This enables 
clinicians  to  review GP  records,  including the  referring  clinician’s working  diagnosis 
and clinical considerations, prior to hospital assessment. 

All  parties  recognised  the  critical  importance  of  timely  access  to  comprehensive 
patient information, and this action was endorsed as a key improvement to support 
safer, more informed clinical decision-making. The system is now fully operational and 
accessible to all Emergency Department staff 

The Trust is undertaking  a review of the Directory of Services with system partners to 
ensure an awareness of services delivered across all local hospitals for both adults 
and paediatrics.  It is envisaged that this will be completed by the end of July 2026. 

Actions taken: 

•  The  Trust  will  undertake  an  evaluation  of  an  electronic  interface  with  the 
Directory  of  Services  for  General  Practice,  with  the  aim  of  ensuring  that  the 
most current and accurate information is consistently accessible to all GPs. This 
work is scheduled for completion by the end of July 2026. 

•  The Trust is developing a coordinated communications programme to clearly 
articulate the range of services provided across GEH and SWFT. This will be 

 
 
 
 
 
 
 
 
 through  multiple  channels, 

disseminated 
including  the  Trust  websites,  NHS  111,  West  Midlands  Ambulance  Service 
(WMAS), and primary care, to support informed referral decisions and promote 
service awareness. 

•  The  Trust  intranet  is  currently  undergoing  review  and  update  to  ensure 
accuracy and accessibility of information. In parallel, the Directory of Services 
for NHS 111 and WMAS has been reviewed and is confirmed to be current and 
up to date. 

6.  General Learning  

Learning from this case has been shared with the whole multidisciplinary team in GEH 
emergency  department  and  beyond.  Further  multi-disciplinary  team  simulation 
sessions (completed monthly), led by the Paediatric Practice Educator, will involve a 
presentation of a neurodivergent patient with abdominal pain.  This case has also been 
discussed at length with the Paediatric Crisis Neurodiversity & Learning Disability Lead 
Nurse from SWFT. 

A  Patient  Forum  survey  is  going  to  be  conducted  to  look  at  patient  and  family 
satisfaction with regard to communication.  This is currently under construction and is 
expected to be finished by the end of June 2026. 

The Trusts would like to thank the coroner’s office again for the opportunity to review 
and  strengthen  the  pathways  of  care  for  our  patients  and  hope  this  answers  your 
outstanding concerns.  As a Trust we strive for excellence in patient care and put the 
patient at the heart of all we do. The Trust uses incidents as an opportunity to learn 
and grow.  

Please do not hesitate to contact me if you require any clarification. 

Yours sincerely 

Chief Nursing Officer

Old Mill Surgery, Marlborough Road,
Nuneaton, Warwickshire, CV11 5PQ

14th April 2026

FAO Linda Lee

Acting Area Coroner for Coventry & Warwickshire

Private & Confidential

Investigation into the death of Ethan Michael Hanson who died on 26th April 2025

Subject: Response to Inquest Report – Actions Taken

Thank you for your inquest report.

I can confirm that an ambulance was in the process of being arranged to transfer Ethan to
hospital. However, due to the anticipated delay, Ethan’s mother chose to take him to George
Eliot Hospital, as it is located approximately four minutes from the Practice. Her decision was
made to avoid any further delay in his assessment within the Emergency Department.

At the time of the incident, the Practice was not aware of the specific paediatric referral
pathways at the hospital, as this information had not been formally communicated to us.

Following this event, we have implemented a new protocol within our EMIS clinical system and
also laminated the protocol and displayed in all clinical rooms. This protocol prompts all
clinicians, at the point of referral, to:

 Confirm the appropriate referral pathway
 Select the correct hospital for paediatric services
 Access and use relevant contact numbers to notify the receiving team in advance
 Complete the necessary referral documentation to accompany the patient
 Arrange ambulance transfer where clinically appropriate

This protocol is now available to all clinicians, including locum doctors and GP registrars in
training and forms part of their induction, with the aim of strengthening our referral processes
and reducing the risk of similar incidents occurring in the future.

Yours sincerely

 Senior Partner

Dr Jamie Hynes FRCGP 
Vice Chair Member Standards 

Mrs Linda Lee 
Acting Area Coroner for Coventry & Warwickshire 

22 May 2026 

Dear Mrs Lee  

Regulation 28 Report to Prevent Future Deaths - regarding the death of Master Ethan Michael Hanson 

Thank you for asking us to comment on the matters of concern following the sad death of Master Ethan 
Michael  Hanson,  who  died  on  the  26th  of  April  2025.  Our  sincere  condolences  go  to  his  family  and 
friends  given  the  difficult  circumstances  and  the  ongoing  questions  on  how  this  could  have  been 
prevented. We will address the issues raised as requested in the hope that the response can help answer 
the concerns of the Coroner and Ethan’s loved ones. 

You have a matter of concern for GPs relating to this tragic death: 

The GP identified the possibility of appendicitis or another serious underlying cause and 
recorded abnormal observations. The absence of an ambulance conveyance or written referral 
letter meant this information was not transferred to the hospital. As a result, Ethan entered a 
different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There 
is a wider risk that GPs may not be aware of the implications of referral route on triage and 
assessment in local hospitals, and that critical deterioration indicators can be lost at the point 
of transfer. 

To give context to the family, The Royal College of General Practitioners works to improve patient 
care by encouraging the highest possible standards in general medical practice by supporting members, 
setting standards, providing education and training, promoting   research, advocating and representing 
the College and its 56,000 members.  

General Practitioners have a broad curriculum, and the College is responsible for the definitive 
educational framework for all doctors undertaking GP speciality training. There are 5 areas of 
capability aligned to the General Medical Council’s Generic Professional Capabilities Framework, and 
these are supported by twenty-two Clinical Topic Guides. Within the Urgent and Unscheduled Care  
Clinical Topic Guide, areas of a GP’s role include aspects relevant to Ethan’s care:  

The importance of providing appropriate documentation and records for each patient contact, 
which must be communicated to the next professional involved with that patient 
Appropriate use of emergency services, including the logistics of communicating with an 
ambulance or paramedic crew and the response time required 

Royal College of General Practitioners 
30 Euston Square, London, NW1 2FB 
Tel: 020 3188 7400  |  info@rcgp.org.uk  | rcgp.org.uk 
Registered Charity Number 223106  |  Patron: His Majesty King Charles III 

 
 
 
 
 
 
 
 
 
 
 
 
  
  
 Strategies for ensuring effective and appropriate communication and escalation of concern 
regarding deteriorating patients to ambulance services, the emergency department (ED) or 
accident and emergency (A&E) and acute service colleagues 

Within NHS England’s 2024 ‘Same Day Emergency Care- service specification’ document the flow 
chart suggests Paediatric SDEC service unless NEWS2 score of over 5, or a score of 3 in a single 
parameter, in which case referral to Emergency Department is indicated- it is not clear if that threshold 
applied here. There is no reference in this specification to primary care communication, nor in the 
2026 ‘Model Acute Pathway: standards for care of acutely unwell patients in their first 72 hours in 
hospital’, developed with the Royal College of Physicians, Society for Acute Medicine and British 
Geriatrics Society, which emphasises availability of senior clinical decision making, usually working at 
Medical Registrar level. 

Work on the interface between primary cand secondary care included a joint statement between 
RCGP, RCP, SAM and Royal College of Emergency Medicine calling for secondary care to improve 
primary care access to specialist advice via dedicated telephone lines and urgent expansion of SDEC 
options for primary care and 111 services. GP Awareness of impact of referral letter and ambulance 
conveyance on clinical pathways within Emergency care, opportunities to communicate this to GPs.  

GP Information Technology Systems record GP Consultations and information such as recorded in 
Ethan’s GP encounter. There is no single GP IT System and suppliers include EMIS, SystmOne and 
Medicus. There is no single Hospital IT System and given this situation, information sharing between 
Primary and Secondary care faces challenges. GPs are faced with a choice under time pressures given 
observations as recorded in Ethan’s consultation, to admit via Paediatric colleagues or direct to the 
Emergency Department. Secondary care pathways will differ between organisations. From a primary 
care perspective, it may seem that the most direct means of rapid assessment will be through ED.  
Added awareness that primary care information and method of hospital transfer influences secondary 
care pathway selection needs to be highlighted to GPs if the existing secondary care pathways remain 
as described. I intend to communicate this issue to members alongside learning from Prevention of 
Future Death Reports in a Webinar format for dissemination of learning, ensuring principles being 
highlighted are generic and not attributable to individual cases, nor impacting ongoing proceedings 
that follow each coronial review. 

Once again, our condolences go to Ethan’s family and friends. I hope the comments provide a full 
picture of where the RCGP can influence the prevention of future deaths within training and 
continuing professional development. 

Yours faithfully 

Vice President Member Standards