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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.”

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Source: The Independent, 18 March 2025

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