Finlay Roberts

th Floor 20 Cavendish Square London W1G 0RN

I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Poplar Coroner’s Court Bow Coroner’s Court

On  19 July 2024, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Finlay Roberts aged 2 years and 11 months. The investigation concluded at the end of the inquest on 9 June 2025. I made a determination at inquest that Finlay died from a rare (in a child) but recognised natural cause, a sigmoid volvulus.

Finlay’s parents took him to the Whittington Hospital the night before he died, but the paediatric emergency department was understaffed and it was an extremely busy night. There was a failure to conduct serial nursing observations; not all tests were carried out as appropriate; and, though specialist advice was sought from Great Ormond Street Hospital, the late arrival of x-rays, a lack  of  complete  information  and  a  failure  to  close  the  loop  of communication meant that the advice was not obtained before Finlay was discharged home. It is unclear whether different hospital care that night would have saved Finlay’s life. It would have given him a chance.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The lack of serial nursing observations was a fundamental omission from Finlay’s  care. I heard at  inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff. However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks. I remain concerned on two counts:

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.

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.