Lessons From The Ethan Hanson Prevention Of Future Deaths Report: Communication Failures, Neurodiversity And Patient Safety

The death of eight-year-old Ethan Michael Hanson has prompted a significant Prevention of Future Deaths (PFD) report, highlighting systemic concerns around primary and secondary care communication, the assessment of neurodivergent patients and families, and the governance of paediatric emergency pathways. The case has also attracted national attention following coverage in The BMJ (peer-reviewed medical journal), which emphasised wider debates concerning patient safety and Advanced Clinical Practitioner roles within the NHS.

Acting Area Coroner Linda Lee concluded that Ethan passed away on 26 April 2025 from septic shock, peritonitis and perforated appendicitis. Following an inquest completed in March 2026, the coroner recorded a conclusion of medical misadventure and issued a Regulation 28 report to NHS England, George Eliot Hospital NHS Trust, the Getting It Right First Time (GIRFT) programme and the Royal College of General Practitioners.

What is a Regulation 28 report

Under the Coroners and Justice Act 2009, a Coroner can issue a Regulation 28 report to an individual, organisations, local authorities or government departments and their agencies where they believe that action should be taken to prevent further deaths.

The Facts of the Case

On 23 April 2025, Ethan attended his GP with abdominal pain and vomiting. The GP documented concerning clinical findings, including a raised temperature and tachycardia (fast heartbeat), and considered appendicitis among the possible diagnoses. Ethan was advised to attend hospital urgently. However, no ambulance was ultimately used and no written referral accompanied him to hospital. As a result, the GP’s findings and concerns were not communicated to the clinician who later assessed him.

Upon arrival at George Eliot Hospital, Ethan was triaged and assessed by an Advanced Nurse Practitioner. According to the Coroner’s findings, no blood tests or urine tests were undertaken, despite his symptoms. Ethan reported severe pain, scoring it 10 out of 10, yet no clinician-assessed pain score was recorded, and no repeat observations were performed. A transcription error also led to incorrect recording of his observations, including his temperature. He was treated for presumed constipation with a phosphate enema and discharged without senior medical review.

The inquest heard evidence that had the temperature been recorded correctly, Ethan would likely have been escalated for registrar or consultant review. A consultant surgeon further stated that, had he reviewed Ethan at the time, appendicitis would probably have been diagnosed.

Following discharge, Ethan’s condition deteriorated significantly. Two days later he suffered a cardiac arrest at home. Hospital investigations confirmed perforated appendicitis, generalised peritonitis and sepsis. Despite transfer to Birmingham Children’s Hospital, Ethan passed away on 26 April 2025.

The Coroner’s Concerns

The Regulation 28 report identifies several areas where the Coroner considered there to be an ongoing risk of future deaths:

• Failure to Transfer Critical Clinical Information

One of the most significant concerns related to the breakdown in communication between primary and secondary care. The GP had recognised the possibility of a serious underlying condition and recorded abnormal observations. However, because Ethan arrived without either ambulance transfer or referral documentation, those concerns were not passed to the hospital team. The Coroner warned that critical deterioration indicators can be lost during transfer and suggested there is a wider risk that GPs may not appreciate how different referral routes affect hospital triage pathways.

From a clinical negligence perspective, the case demonstrates how adverse outcomes can arise not from a single error but from a series of communication failures across organisational boundaries.

• Record-Keeping and Digital Safeguards

The report also criticised the absence of electronic safeguards capable of preventing incomplete or inaccurate clinical observations from being recorded. The transposition (or transcription?) error concerning Ethan’s temperature and oxygen saturation became a critical factor in the assessment process. The Coroner noted that mandatory fields or “hard-stop” requirements within electronic systems could help prevent such omissions and errors from influencing clinical decision-making.

The findings reinforce the importance of robust digital safeguards and accurate record-keeping in emergency care settings.

• Neurodiversity and Clinical Assessment

The report also raised concerns regarding the assessment of neurodivergent children and families. Ethan was autistic and awaiting ADHD assessment. His mother was also neurodivergent. The Coroner observed that, although national GIRFT (“Getting It Right First Time”) guidance recognises challenges in assessing neurodivergent children, it provides limited practical assistance for clinicians on adapting communication, history-taking and pain assessment.

Evidence at the inquest suggested that hospital staff perceived Ethan and his mother as “reassured” by the discharge plan. However, Ethan’s mother later explained that she remained concerned but felt unable to challenge or question clinicians effectively. The Coroner warned that healthcare providers may wrongly interpret apparent agreement as genuine reassurance when neurodivergence affects communication.

This aspect of the report reflects a growing recognition within healthcare and legal practice that reasonable adjustments for neurodivergent patients and families must extend beyond formal diagnosis and include practical communication strategies.

Wider Implications

The case has been discussed within a broader national debate regarding Advanced Clinical Practitioner roles. The BMJ noted that concerns have recently been raised regarding the scope of practice of Advanced Nurse Practitioners and the management of undifferentiated patients. However, importantly, the Coroner did not specifically criticise the Advanced Nurse Practitioner role itself and did not identify the Practitioner’s professional status as the cause of Ethan’s death. Instead, the focus remained on systemic failures, communication gaps and pathway design.

George Eliot Hospital NHS Trust has accepted the Coroner’s findings and has stated that action is being taken to address the identified concerns. Meanwhile, Ethan’s GP practice has implemented a revised protocol requiring clinicians to notify receiving teams, complete referral documentation and arrange ambulance transfers where appropriate.

Importance to Clinical Negligence claims

The case is particularly significant in clinical negligence claims because it illustrates how breach of duty may arise through cumulative system failures rather than one isolated clinical error. In claims involving delayed diagnosis, emergency department discharge, paediatric assessment or failed escalation, the report provides a useful example of how referral information, observations, pain scoring, safety-netting and senior review may all be relevant to whether care fell below a reasonable standard.

It also sits alongside the wider scrutiny of clinical role clarity reflected in the 2025 Leng Review into physician and anaesthesia professions. Although the Hanson case concerned an Advanced Nurse Practitioner, rather than a physician or anaesthetist, the same themes are relevant to clinical negligence analysis: whether patients were assessed by an appropriately trained professional, whether the clinician was working within a clearly defined scope of practice, whether there was adequate supervision and if escalation pathways were sufficiently robust.

Conclusion

The Ethan Hanson PFD report serves as a powerful reminder that patient safety depends on far more than individual clinical judgment. Effective communication between healthcare providers, reliable electronic systems, appropriate escalation pathways and meaningful consideration of neurodiversity all play a crucial role in preventing avoidable harm.

For healthcare organisations, the report highlights the need to review referral processes, documentation standards and support mechanisms for neurodivergent patients and families. The case provides an important example of how multiple systemic shortcomings can combine to produce catastrophic outcomes, even where individual clinicians may each have acted within what they believed to be an appropriate framework.

As NHS bodies consider their responses to the Coroner’s recommendations, the lasting legacy of Ethan’s case may be a renewed focus on ensuring that critical information is never lost between healthcare settings and that the needs of neurodivergent patients are embedded more effectively into everyday clinical practice.

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