Can lessons be learned from the tragic death of four year old Daniel Klosi due to sepsis?

Daniel Klosi, from Camden in London, sadly died in April 2023 from sepsis. Following an inquest into his death, the coroner has now published a ‘Prevention of Future Deaths’ report, which may help lessons to be learnt to prevent similar tragedies from occurring.

Between March and April 2023 Daniel Klosi was taken by his parents to Accident and Emergency at the Royal Free Hospital in London on four separate occasions:-

1. The morning of Sunday, 26 March 2023
2. The early morning of Friday, 31 March 2023
3. The morning of Saturday, 1 April 2023
4. The afternoon of Saturday, 1 April 2023.

Following the first three attendances Daniel  was discharged. It was after 9pm on Saturday 1 April 2023 that Daniel was diagnosed with sepsis. He died shortly after midnight on 2 April 2023.

An inquest was held, and on 14 August 2024 the coroner, Mary Hassell, gave a narrative verdict, which identified a number of factors which contributed to Daniel’s death.

Prevention of Future Deaths report

Following this, on 16 August 2024 the coroner made a ‘Prevention of Future Deaths report’, which was addressed to the Royal Free Hospital, the Royal College of Paediatrics and Child Health and the Royal College of Emergency Medicine.

The report explained that some changes had already been introduced at the Royal Free Hospital.

However, the report stated that the coroner considered that some areas of concern would benefit from further consideration by the Royal Free Hospital, and that the issues are likely to be applicable nationally. Two areas were highlighted in the report:

“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.

2. 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”.

The Royal Free Hospital, the Royal College of Paediatrics and Child Health and the Royal College of Emergency Medicine must respond to the report by 14 October 2024.

Daniel’s tragic death may therefore hopefully result in improvements to practices and procedures in hospitals nationally.

Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs, with the immune system going into overdrive.

Sepsis can lead to shock, multiple organ failure and death if not recognised and treated promptly.

You can find more information on how to spot the signs of sepsis here.

If you have been impacted by sepsis, our experienced clinical negligence lawyers are always happy to talk.