Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed or missing clinical observations in pediatric emergency care
The earlier warning
Daniel Klosi · 16 Aug 2024 · Mary Hassell, Inner North London
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.”
judiciary.uk/…/daniel-klosi-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Daniel Klosi (16 Aug 2024) · stated timescale: none stated
“I intend to make a prevention of future deaths report”
Stated action 2 · response to Daniel Klosi (16 Aug 2024) · stated timescale: none stated
“We will continue to be strongly supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.”
Stated action 3 · response to Daniel Klosi (16 Aug 2024) · stated timescale: 2025
“We 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”
3 further stated actions are listed on the full chain page.
What recurred
- 20 Jun 2025 · Finlay Roberts · Mary Hassell · Closely related · confidence 0.92 (high)
- 4 Mar 2026 · Viviana-Ray Butnaru · Jyoti Gill · Closely related · confidence 0.87 (high)
The clearest link, quoted from both reports:
Earlier · Daniel Klosi · 16 Aug 2024
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.”
Later · Finlay Roberts · 20 Jun 2025
“The lack of serial nursing observations was a fundamental omission from [the deceased]'s care.”
What happened next
No web check of the stated actions has been published for this chain.