Clara Iris Moniatis · Prevention of Future Deaths report

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Issued 3 Nov 2020•Essex

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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

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

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

  1. Barts Health NHS Trust

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

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

  1. Barts Health NHS Trust

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

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Barts Health NHS Trust

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

    Disputes 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