A coroner has voiced serious concerns over a recurring “lack of observations” at London’s Royal Free Hospital following the death of a teenager.
Sixteen-year-old Billie Wicks died after suffering her first ever asthma attack. Her parents rushed her to the Hampstead hospital on 17 September last year, but a new report reveals the A&E department was “understaffed” that night.
The coroner’s concerns highlight a potential systemic issue at the hospital regarding patient monitoring.
Senior coroner for Inner North London, Mary Hassell, said that Billie should have had routine checks, or observations, taken every hour.
If she had these observations, then medics would have recognised the severity of Billie’s illness, Ms Hassell said.
“Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived,” she wrote in a prevention of future deaths report.
“Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review.
“That senior medical review would have changed the course of her management and saved her life.”
Meanwhile, Ms Hassell also mentioned the case of four-year-old Daniel Klosi – who died from sepsis at the Royal Free in 2023.
Daniel was taken to hospital four times in the week running up to his death, and a report into the circumstances surrounding his death also raises concern about observations.
“Following the inquest touching the death of Daniel Klosi, I wrote to you on August 16 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme,” Ms Hassell said.
Meanwhile, Ms Hassell also raised concerns about “safety-netting”.
She wrote: “Billie 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. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff.
“It is therefore difficult to see how this particular advice could be a meaningful instruction.
“In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital.”
She also highlighted staffing issues in the department, adding: “At inquest, I heard repeatedly that on the night Billie 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.”
The report does say that a first case of asthma at the age of 16 without any family history is “unusual”.
A spokesperson for the Royal Free London said: “We would like to share our heartfelt condolences with Billie’s family and to say how sorry we are that she died while under our care.
“Following an investigation into the care provided to Billie, we have taken steps to increase staffing levels in the children’s emergency department during nights and weekends and improve the process for alerting senior clinicians when an abnormal test result is received.
“We will carefully review the coroner’s findings and respond to all the matters she has raised.”