Daniel Klosi

Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London  N1C 4PP

On 12 April 2023, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Daniel Klosi, aged 4 years. The investigation concluded at the end of the inquest on 14 August 2024. I made a narrative determination at inquest, a copy of which I attach.

Daniel died on his fourth presentation in a week to the Royal Free Hospital. His medical cause of death was: 1a group A streptococcus sepsis

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The Royal Free NHS Trust divisional director of women and children’s services  gave  evidence  at  inquest  of  the  changes  that  have  been introduced since Daniel’s death. More training has been given and reflection has been undertaken. A child reattending the emergency department will now be seen by the next available doctor, rather than waiting for a paediatrician to become available. The trust is trying to gain a more sophisticated understanding of the ways in which neurodiverse patients can present and how best to interpret their presentation. There is now to be a national change to allow 111 services to contact emergency departments direct. However,  it  seemed  that  some  areas  would  benefit  from  further consideration by the trust.  And all of the issues are likely to be just as applicable nationally.

1. It was difficult for the nursing staff to obtain Daniel’s observations because he was so distressed.   That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance Daniel did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise. I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations, and should be escalated without delay.

It seems that this has not been emphasised explicitly to nursing and medical staff at the trust – and obviously may not have been in other trusts.

1. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments.

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.