The parents described a “nine-hour NHS nightmare” including waiting for hours in the corridors before Finlay was seen.
Finlay was discharged at around 1am the follow day without having had full observations done and with only one partial set of observations completed throughout the whole nine hours.
At around 8am the next morning Elizabeth woke to find her son lifeless on the bed next to her, he had died due to a twisted bowel condition called sigmoid volvulus.
Coroner Mary Hassell has now issued a Prevention of Future Deaths report, warning of the risk of future loss of life if action is not taken.
While it was not clear whether proper hospital care would have saved Finlay’s life, Coroner Hassell said “it would have given him a chance”.
Whittington Health NHS Trust said they are determined to learn from Finlay’s death (Image: Google Maps) Ms Hassell said: “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.”
The coroner likened the death to another inquest she dealt with, in which 16-year-old Billie Wicks died following a lack of regular observations at the Royal Free Hospital in Hampstead.
“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,” she said.
Finlay’s parents, David and Elizabeth Roberts, 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.
“We have set up ForFinny.com to raise money for charities in his memory.”
The family were represented by the medical negligence team at Leigh Day.
Leigh Day partner Maria Panteli said: “Elizabeth and David Roberts have shown remarkable courage as they have navigated this difficult process.
“Finlay’s death has shone a light on the importance of serial nursing observations and highlighted staffing issues within the Whittington’s paediatric emergency department.
“In response to Finlay’s death, we understand the Whittington has since hired more nursing staff.
“In light of the coroner’s Prevention of Future Deaths Report, we hope that a thorough review of practices and policies at the Whittington may serve to prevent similar instances occurring.”
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.”
