Our son, 2, died in his bed hours after being sent home from understaffed hospital
Finlay Roberts, 2, tragically passed away after suffering from a twisted bowel condition - sigmoid volvulus - a "rare but recognised natural cause," coroner Mary Hassell said during an inquest into his death.
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The tot's parents, David and Liz, explained how they had taken their son to A&E after he awoke with a tummy ache before enduring a "nine-hour NHS nightmare" on July 11, last year.
David said they waited a "number of hours" at the understaffed paediatric A&E department Whittington Hospital in North London before he eventually pushed through to get Finlay seen to.
He told ITV how the family spent most of their time sitting on chairs in the corridor, with Finlay even being examined while perching on his knee in the walkway.
Despite eventually being discharged at around 1am, the tot tragically died just hours later, with Liz waking up to find him not breathing in the bed next to her.
Coroner Hassell said that while it was unclear whether Finlay's life could have been saved, "it would have given him a chance" if hospital care had been delivered properly.
She has also now issued a prevention of future deaths (PFD) report, highlighting concerns that a lack of serial nursing observations was a fundamental missing component from Finlay's care.
The inquest further found that routine checks were not carried out by hospital staff and that there were communication failures.
Liz said: "He wasn't given a chance. He should have been, because he was just two-years-old, but there were a litany of failures that meant that he was robbed of that chance."
David added that he felt the system was "flagrantly broken", saying: "The problems with the NHS are really clear, for us they are beyond viscerally clear - something went catastrophically wrong.'
The pair are also sceptical over recently announced government plans for the NHS to "fundamentally re-wire" the health service to give patients "easier, quicker and more convenient care".
David believes more radical change must be done, instead of "performative little tricks around the edges".
Marking almost one year since Finlay died, Liz says the family have been struggling to have confidence after everything they've been through.
David added that it was impossible to put their pain into words, describing their feelings as an "eternal flatness", saying that life without him felt "intolerable".
Coroner Hassell's issuance of a PFD report highlights the severity of Finlay's case, with roughly just one per cent of all inquests in 2023 resulting in one.
In the report, the following factors were listed in the circumstances of Finlay's death: "not all tests were carried out as appropriate; and, though specialist advice was sought from Great Ormond Street, the late arrival of X-rays, a lack of complete information and a failure to close the loop of communication meant that advice was not obtained before Finlay was discharged home'.
The tot was unable to have scans done at the Whittington Hospital - as these were unavailable out of hours - but his parent's requests for a transfer to Great Ormond Street, where tests would have been available, were not granted.
A twisted bowel, or volvulus, is when the intestine gets twisted which can cause a blockage and cut off the blood flow.
In children, it can be the result of a birth defect, known as intestinal malrotation.
It's when the baby's intestinal tract doesn't form as it shouldn't during pregnancy.
Most children have symptoms within the first year of life, but some can go their whole lives without any and are never diagnoased.
Symptoms can happen a bit differently in each child. They can include:
Vomiting green digestive fluid (bile)
Drawing up the legs
Stomach pain
Swollen belly
Diarrhoea
Constipation
Rectal bleeding
Failure to thrive
Fast heart rate
Fast breathing
Bloody stools
Source: University of Rochester Medical Center
The inquest was told that during Finlay's time in the Emergency Department from 4.15pm on 11 July 2024 until he was discharged at around 1am on 12 July 2024, he didn't have full observations done.
Just one one partial set of observations was completed throughout the whole nine-hour ordeal.
This is despite doctors telling the inquest that observations should be done at least every four hours in the Emergency Department.
Records indicate Finlay was discharged without observations but advised to return the next day.
However, at around 8am, Liz awoke to a crackling noise, with Finlay laying lifeless in the bed next to her and not breathing.
Despite their desperate attempts to resuscitate their toddler, and efforts by paramedics and doctors at the Whittington Hospital, he passed away on July 12, exactly one month before his third birthday.
Ms Hassell's PFD report also noted how she had raised similar concerns over a lack of regular paediatric nursing checks following an inquest into the death of Billie Wicks, 16, at the Royal Free Hospital on September 15, 2024.
She cautioned that the lack of nursing observations could be a "much wider issue" than is recognised.
Ms Hassell also highlighted that medical staff at the hospital failed to recognise the lack of nursing observations.
'OUR LIVES WILL NEVER BE THE SAME'
In a touching tribute to their son, David and Liz said: "We are simply devastated by Finny's death. He was the happiest and most loved of little people.
"Our lives will never be the same. We remain thankful for the nearly three years we had with him they were filled with joy and happiness.
"We desperately wish there could have been more."
The couple have also setup a website to raise money for charities in Finlay's memory - you can donate to it here.
Maria Panteli, who represented the parents, said she understood that the hospital had since hired more nursing staff.
A spokesperson for Whittington Health NHS Trust said: 'We offer our sincere condolences to Finlay's family.
"Following an investigation led by a consultant from an external organisation, we have made changes to our services.
"We are also planning further improvements based on the coroner's findings around how we conduct and record observations.
"We are determined to learn from the heartbreaking events around Finlay's death and improve the care and support that we provide.'
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