The tragic death of 2 year old Finlay Roberts has once again highlighted serious concerns about the treatment of children in busy Hospital Emergency Departments, particularly the failure to recognise deterioration, inadequate monitoring and the risks associated with overcrowded Hospital environments.

Finlay died in July 2024 after attending the Whittington Hospital in North London with abdominal pain. He spent approximately 9 hours in the Paediatric Emergency Department, much of that time sitting with his parents in a corridor, before being discharged home in the early hours of the morning.

His death was subsequently investigated at an Inquest which concluded in June 2025. The Coroner found that Finley had died from a sigmoid volvulus, a rare but recognised condition in children in which the bowel twists, potentially causing a life-threatening obstruction.

The Inquest identified a number of shortcomings in the care he received. These included a failure to undertake regular nursing observations, investigations that were not appropriately completed and communication failures relating to specialist advice sought from Great Ormond Street Hospital. Delays in obtaining x-rays and incomplete information meant that the specialist advice was not received before Finley was discharged.

Importantly, the Coroner concluded that although it was unclear whether different Hospital care would have saved Finlay’s life, it would have given him a chance.

One of the most convincing findings was the failure to undertake serial nursing observations throughout Finlay’s attendance.

The Coroner described the absence of regular observations as a fundamental omission from his care. She also raised concerns that medical staff had failed to recognise that observations had not been undertaken at all.

A child’s clinical condition can change rapidly, and an initial assessment does not necessarily provide an accurate picture of their condition several hours later. Regular monitoring allows healthcare professionals to identify changes in vital signs and recognise when a child may be becoming increasingly unwell. Without appropriate observations, deterioration may go unnoticed, potentially delaying investigations, treatment and escalation to senior colleagues.

The case also raises questions about the safety of treating seriously unwell children in corridors and other unsuitable clinical environments, where privacy, dignity, monitoring and access to appropriate clinical resources may be compromised.

National Paediatric Early Warning System (PEWS)

The National Paediatric Early Warning System (PEWS) is a standardised system being introduced by NHS England. PEWS is designed to help healthcare professionals identify when a child or young person is becoming clinically unwell and ensure that appropriate action is taken.

The System incorporates the recording and assessment of observations, including:

• Heart Rate.
• Respiratory Rate.
• Oxygen saturation.
• Blood pressure.
• Temperature.
• Level of consciousness and other clinical indicators.

These observations contribute to an early warning score. An increasing score indicates that a child may require more urgent clinical assessment and intervention.

However, PEWS is much more than a numerical scoring system. It incorporates clear escalation procedures, communication between healthcare professionals and consideration of concerns raised by parents and carers.

Crucially, parental concerns should not be dismissed simply because a child’s numerical score is low. If a parent believes their child is becoming more unwell, this should prompt an appropriate clinical response.

Finley’s case illustrates several areas of clinical care that may be relevant when investigations potential clinical negligence claims involving children.

• Failure to undertaken observations
• Failure to recognise and respond to deterioration
• Failure to escalate concerns
• Inadequate communication and failure to obtain specialist advice
• Inappropriate discharge

The introduction of National PEWS into Emergency Departments represents an important step towards improving the recognition and management of deteriorating children. It also reinforces the importance of carefully investigating the assessment, monitoring and ongoing management of children attending Hospital.

Finlay Roberts’ death is a heartbreaking reminder of the importance of listening to parents, undertaking regular observations and recognising when a child is becoming increasingly unwell.