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recurance

Billie Wicks

17 Mar 2025 · Coroner Mary Hassell · Inner North London

The coroner's concerns

  1. 1. understaffed emergency department

    “At inquest, I heard repeatedly that on the night [the deceased] attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations.”
  2. 2. delayed antibiotic administration

    “The registrar who saw [the deceased] the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that [the deceased]'s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.”
  3. 3. lack of awareness of adult onset asthma

    “At the time of [the deceased]'s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need.”
  4. 4. ineffective safety netting advice

    “I heard that [the deceased] was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests.”
  5. 5. absence of blood pressure in PEWS

    “Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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