A key chance to save the life of a four-year-old boy who died from sepsis after being taken to hospital four times in a week was missed, a coroner has said.
Daniel Klosi died from sepsis at the Royal Free Hospital in Camden, north London, in the early hours of April 2 last year, having been taken to the hospital emergency department four times in a week, including twice in one day, by his anxious parents.
Senior coroner Mary Hassell made the observation as she gave a narrative determination at the inquest into Daniel’s death, where his parents remembered him as a “lively boy” with no health issues other than his autism.
The coroner said Daniel’s illness had been ongoing for a week by his third trip to the hospital but at this point his medical records were not looked at properly and a chance to give antibiotics that “would have saved” his life was missed.
The coroner, sitting at Poplar Coroners Court in east London, on Wednesday also said she had given “full consideration” as to whether there had been neglect in Daniel’s case but decided it was not appropriate.
She was speaking after a number of medical staff had given evidence, along with paediatrician Dr Tim Wickham, a consultant paediatrician at the Royal Free NHS Foundation Trust who led an investigation into the incident and told the inquest: “I think we failed him in that we did not recognise how ill he was.”
He added: “He was the illest patient throughout the entire evening. He was going into septic shock and we did not recognise it.”
Daniel’s father Kastriot Klosi, who is a care assistant, and mother, Lindita Alushi, who is a pharmacy assistant – dabbed away tears after the inquest.
The coroner said Daniel, from Kentish Town, north London, was brought to the emergency department four times and was not admitted until the final occasion when he “was acutely septic”.
She described the first and second discharges as “reasonable and understandable” but that by the fourth occasion Daniel had “begun the process of sepsis but I do not know whether antibiotics on that fourth admission would have saved him.”
The coroner said “it seems to me that Daniel could have been helped” on that third visit.
She noted: “There was a failure on that occasion to read the medical record properly, to understand that this was the third attendance, to understand more specifically that this illness had been going on for a week.”
This information could have been gained from looking at the records or from Daniel’s father but “it was not explored and consequently the need for antibiotics was not recognised” and the boy was discharged, Ms Hassell added.
Daniel had faced delays in being seen by doctors and there had been an “inability to obtain observations” and “the need for that to be escalated” was not recognised.
The coroner said Daniel came in with an “atypical presentation of sepsis” and there was a “lack of understanding” of how to view the needs of a neurodivergent child.
Earlier, consultant paediatrician Alexandra Pledge had told the inquest Daniel’s “rapid decline was shockingly fast” and described sepsis as “unpredictable”.
Daniel got more agitative and combative when a healthcare professional was around, which is an unusual sign in a child suffering sepsis.
He had impaired circulation but was alert and able to say that he wanted to go home.
On whether there was a time on which more aggressive treatment could have saved Daniel, Dr Pledge said: “I think that if he had antibiotics in the first part of the day, on the balance of probability he could have been salvaged.”
Dr Wickham also told the court: “It strikes me clearly that was a missed opportunity on the third attendance.”
He said he was “surprised” that a child could come in to the department and return with similar symptoms without further investigations having been made.
He added: “For me that was the moment where we could have made the difference – it was that morning.”
He added: “Daniel was sitting in a busy queue and his parents were watching other children come in who looked less sick than their child and they were seeing them get in and see a doctor.”
Dr Wickham said changes have been made since Daniel’s death, urged on by the staff who had been “profoundly affected at the time of what had happened”.
He said someone who reattends the hospital will now be seen by the next available doctor.
Dr Wickham also said that medics wanted to “do better” and see that lessons must be learned in how they deal with neurodivergent children.
He told the court that the medics were reflecting on “how can we communicate with them better and instigate triage, how the parents are spoken to (as) it will help with how the parents feel they are getting care in the department.”
The inquest had heard that on March 26, Daniel’s parents noticed he was “wheezing and had a barking cough”, and took him to the Royal Free emergency department, where he was diagnosed with crepitation of the lungs.
Mr Klosi’s inquest statement said they returned on March 30 when a doctor and nurse said Daniel had picked up a virus, and that he should “go home and rest”.
The parents called 111 and were booked in for triage at the hospital on April 1 after Daniel “suddenly stopped eating and drinking”, and he was seen at about 1pm.
Mr Klosi also said he was “told his chest was clear and he was suffering from a virus” but “felt as if the doctor was fixated on telling me Daniel had a virus rather than finding out what the real problem was”.
After Daniel was again discharged, the family, went back at about 4.30pm and he started “deteriorating” in front of them, his nose, hands and feet “turning purple” and his lips becoming cracked and blue.
After the hearing, a Royal Free London spokesman said: “This is a desperately sad case and we are deeply sorry that Daniel died while under our care.
“We would like to share our heartfelt condolences with his family and loved ones.”
