PFD report

Clara Iris Moniatis · Prevention of Future Deaths report

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Issued 3 Nov 2020•Essex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Delays in review of chest x-ray imaging
  2. Lack of a system ensuring prompt clinical review after PEWS alerts
    Part of recurring concern: Unreliable paediatric early warning score (PEWS) systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Share learning about early senior review of deteriorating patients and PEWS escalation protocols widely among clinical staff.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 December 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    No additional intervention would have prevented the outcome, given the senior specialist review within 20 minutes of the PEWS increase.

    Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in review of chest x-ray imaging

Wider context from the report

“1. The matter of waiting times from chest x-ray to the review of the imaging ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a system ensuring prompt clinical review after PEWS alerts

Wider context from the report

“2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review ”

Is this part of a recurring concern?

Yes — Unreliable paediatric early warning score (PEWS) systems.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share learning about early senior review of deteriorating patients and PEWS escalation protocols widely among clinical staff.

Verbatim wording from the response

“Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff.”

Source location

2020-0221-Response-from-Barts-Health-NHS-Trust.pdf
Page 1 · response
Published 17 December 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

No additional intervention would have prevented the outcome, given the senior specialist review within 20 minutes of the PEWS increase.

Verbatim wording from the response

“Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff.”

Source location

2020-0221-Response-from-Barts-Health-NHS-Trust.pdf
Page 1 · response
Published 17 December 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Documented chest X-ray review timings represent maximum intervals because notes are often recorded retrospectively in the busy emergency department.

Verbatim wording from the response

“We have previously noted that the documented timings of x-ray review represent a maximum time, as notes are often made in retrospect within a busy emergency department.”

Source location

2020-0221-Response-from-Barts-Health-NHS-Trust.pdf
Page 1 · response
Published 17 December 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026