Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0462, written 16 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Aug 2024 |
|---|---|
| Reference | 2024-0462 |
| Deceased | Daniel Klosi |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Daniel KLOSI (died 02.04.23)
THIS REPORT IS BEING SENT TO:
1.
2.
3.
Medical Director
Royal Free Hospital
Pond Street
London NW3 2QG
President
Royal College of Paediatrics and Child Health
5-11 Theobalds Road
London WC1X 8SH
President
Royal College of Emergency Medicine
Octavia House
54 Ayres Street
London SE1 1EU
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 12 April 2023, one of my assistant coroners, Jonathan Stevens,
commenced an investigation into the death of Daniel Klosi, aged 4 years.
1
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.
4
CIRCUMSTANCES OF THE DEATH
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
5
CORONER’S CONCERNS
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.
2
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.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 14 October 2024. I, the coroner, may extend
the period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
•
• HHJ Alexia Durran, the Chief Coroner of England & Wales
, Daniel’s parents
and
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. She may send a copy of this report to any person who
she believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
3
9
DATE SIGNED BY SENIOR CORONER
16.08.24 ME Hassell
4
Daniel KLOSI - determination on 14.08.24 This has been an inquest on behalf of Our Sovereign Lord The King by me, Mary Elizabeth Hassell, Senior Coroner for Inner North London, touching the death of Daniel Klosi who died on 2 April 2023 at the Royal Free Hospital, Pond Street, London. I make a narrative determination as follows. “Daniel Klosi died shortly after midnight on Sunday, 2 April 2023 from sepsis that developed following a chest infection. In the week preceding his death, Daniel’s parents took him to their local hospital accident and emergency department on four 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. On the fourth attendance at approximately 4.45pm on Saturday, 1 April 2023, Daniel’s septic process had begun. This was not recognised until after 9pm. Factors contributing to the non recognition were as follows: • a delay in medical assessment caused by an extremely busy department; • an inability to obtain observations not being recognised as requiring escalation; • some presenting features that were very atypical of sepsis; • a lack of recognition at a profound level of the different in way in which a septic neurodivergent child (in this case, with autism) can present (in this case, appearing to healthcare professionals to be alert when in reality he was agitated) and the consequent need to pay even more attention than usual to parental description. However, it is unclear whether earlier diagnosis and treatment on the fourth attendance would have changed the outcome. On the third attendance, the consultant who assessed Daniel: • • failed to read his medical records; and failed to elicit a full parental history; and so did not know that this was his third presentation in a week. She knew about the second presentation but did not read the record of that presentation. Crucially, this meant that the consultant failed to appreciate that Daniel’s current illness had been ongoing for a week (from Saturday, 25 March to Saturday, 1 April). As a consequence, she failed to order blood tests. These would have demonstrated a very elevated C-reactive protein (CRP). Intravenous antibiotics would then have been administered. Daniel’s life would have been saved.” I intend to make a prevention of future deaths report.
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
M E Hassell Senior Coroner for Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 27th August 2024 Dear Ms Hassell, Further to your prevention of Future Deaths Notice following the conclusion of your inquest (14th August 2024) into the death of Daniel Klosi who died (aged 4 years old) on 2nd April 2023, we would like to extend our sympathy and condolences to the parents, family and friends of Daniel. Daniel attended the emergency department with the same symptoms on three previous occasions prior to his final attendance. Daniel was a neurodivergent child who presented with atypical features of sepsis to an extremely busy emergency department in whom staff struggled to gain observations. Daniel’s condition rapidly deteriorated prior to treatment with antibiotics and his cause of death was Group A Streptococcus sepsis. The Royal College of Emergency Medicine (RCEM) has specific guidance for patients who re- attend emergency departments within 72 hours [1] to ensure that they are reviewed by a senior doctor. RCEM have also endorsed the Royal College of Paediatrics and Child Health Standards in Emergency Care document [2]. RCEM have also produced specific educational material relating Group A Streptococcus [3,4]. RCEM have recently published a Learning Disabilities toolkit [5] as well as an accompanying article on Learning Disabilities in the supplement of the Emergency Medicine Journal [6]. I am sure you are also aware that the Oliver McGowan training programme on Learning Disability and Autism is now a mandatory requirement for healthcare workers [7]. We note that Daniel was taken to an emergency department that was clearly struggling to cope with the demands which were being placed upon it, resulting in long waits. As a medical royal college, we have been raising concerns nationally for a considerable period of time regarding the adverse consequences of prolonged length of stay in EDs / ED Crowding. Our own publication highlights the consequences of ED crowding and its negative impact on adverse events, prolonged hospital stays, and increased mortality and morbidity [8]. Delays in assessment and diagnosis are features of crowded emergency departments; the Health Services Safety Investigation Body (HSSIB) have published a series of reports which also highlights the impact of these same factors in patient safety incidents [9]. We are also aware that there have been several other Prevention of Future Death Notices from other Coroners pointing out the adverse consequences of prolonged emergency department waits [10]. The RCEM is an active participant in the national initiative to develop an early warning score (that utilises observations or vital signs) that is specifically designed for use on all children attending emergency departments, following the implementation of a paediatric early warning score for children who are in hospital wards [11]. We will continue to be strongly supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs. With regards your specific concerns about emergency department electronic patient records (EPR) and their configuration to show how many times a patient has presented to hospital with the same signs and symptoms as their current presentation, we feel this question is best directed towards NHS England. Yours sincerely, Chair, Quality in Emergency Care Committee 1.https://res.cloudinary.com/studiorepublic/images/v1635599020/Consultant_Sign_Off_Standard_June_2016/Co nsultant_Sign_Off_Standard_June_2016.pdf?_i=AA Accessed 27.08.2024 2. https://www.rcpch.ac.uk/sites/default/files/2018-06/FTFEC%20Digital%20updated%20final.pdf Accessed 27.08.2024 3. https://www.rcemlearning.co.uk/foamed/gas-igas-and-scarlet-fever/ Accessed 27.08.2024 4. https://rcem.ac.uk/group-a-strep-and-scarlet-fever-during-a-time-of-winter-pressures-a-joint-statement-from- rcpch-rcem-and-rcgp/ Accessed 27.08.2024 5. https://rcem.ac.uk/wp-content/uploads/2024/09/Learning_Disabilities_Toolkit_v2.pdf Accessed 09.09.24 6. https://emj.bmj.com/content/emermed/suppl/2024/07/22/41.8.DC1/emjsupp_41_s8.pdf accessed 27.08.2024 7. https://portal.e-lfh.org.uk/Component/Details/781480 Accessed 09.09.24 8. https://rcem.ac.uk/wp-content/uploads/2024/01/RCEM_Crowding_Guidance_Jan_2024_final.pdf Accessed 27.08.2024 9https://www.hssib.org.uk/patient-safety-investigations/harm-caused-by-delays-in-transferring-patients-to-the- right-place-of-care/ Accessed 27.08.2024 10. Hodgson et al. Thematic analysis of ‘Prevention of Future Deaths’ reports related to emergency departments in England and Wales 2013–2022. Emerg Med J 2024;41:184-186. https://emj.bmj.com/content/41/3/184 Accessed 27.08.2024 11. https://www.england.nhs.uk/get-involved/cyp/pews/ Accessed 27.08.2024
Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 14 October 2024 Sent by email to: Dear Mr. Hassell, Re: RCPCH Response to the Inquest Touching the Death of Daniel Klosi A Regulation 28 Report – Action to Prevent Future Deaths Thank you for sharing your report with us regarding the tragic and untimely passing of Daniel Klosi. I was very sorry to hear of Daniel’s death. I have shared your report with other senior paediatric colleagues within RCPCH. We have read your report carefully. You mention two areas which would benefit from further consideration. 1. I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations and should be escalated without delay. This is an area of uncertainty. There are lots of reasons why observations might not be obtainable. Observations are important but are part of a holistic assessment of children. As a college we are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK. Our Facing the Future standards aim to provide a vision of how paediatric care can be delivered to provide a safe and sustainable, high-quality service that meets the health needs of every child and young person. There are standards covering emergency settings. These standards aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of audit, review and revision and update of our current standards, to be published in 2025. Two of the Emergency care standards have particular relevance: • Standard 17 – All children attending emergency care settings are visually assessed by a doctor or nurse immediately upon arrival with clinical assessment undertaken within 15 minutes to determine priority category, supplemented by a pain score and a full record of vital signs. • Standard 44 – Emergency clinicians with responsibility for the care of children receive training in how to assess risk and immediately manage children’s mental health needs and support their family/carers. Training should include risk assessment, current legislation on parental responsibility, consent, confidentiality and mental capacity.’ As mentioned, an update to the standards is currently underway. This update will provide guidance on necessary adjustments for children and young people who are neurodivergent. 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 Responsibility for electronic records lies with the NHS. As a college we have called for improved data and digital solutions in our Blueprint for Transforming Child Health Services. Effective data linkage and information sharing within the health system, and between the health system and key partners in education and children’s social care is vital to understanding children’s health needs, recognising risk of harm, and providing effective care. We will continue to advocate on this as a priority in the development of the new 10 Year Plan for the NHS in England. Additional to the points you raise, please can we draw your attention to recognition, diagnosis and early management of Sepsis for which we provide links to relevant clinical guidance within our clinical guidance directory. We provide formal support to the NICE quality standard on sepsis; this is currently under review as part of recent updates to the NICE Sepsis Guidance. The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The anonymised information within your report, and anticipated response from NICE, will also be shared for discussion with the RCPCH Clinical Quality in Practice Committee, where further actions may be identified. Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Daniel’s family. Yours sincerely RCPCH President
Royal Free London Hospital Group, Pond Street, London NW3 2QG Phone: 020 7794 0500 Private and Confidential Senior Coroner ME Hassell Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Via email IC 16 October 2024 Dear Madam RE: Regulation 28: Prevention of Future Deaths report - Daniel KLOSI (died 02.04.23) We write to you in response to the Regulation 28: Prevention of Future Deaths report following the Inquest touching the death of Daniel Klosi. The Royal Free London NHS Foundation Trust has carefully considered the matters of concern raised in the Regulation 28 report. At the inquest, The Royal Free London NHS Trust Divisional Director of Women and Children’s services gave evidence that changes have been introduced since Daniel’s death: “More training has been given and reflection has been undertaken”. The Royal Free Hospital Paediatric Emergency Department team can confirm that training has occurred in relation to children with a deteriorating condition. This links to the use of the Paediatric Early Warning Score tool as well as the identifying sepsis tool. Staff have also been re-familiarised with escalating this information using the SBAR (Situation, Background, Assessment, Recommendation) communication tool. A child who has a deteriorating condition Nurse Champion has been appointed as a senior nurse with a specialist interest in this situation. This person is responsible for leading on training with members of the paediatric nursing team and for undertaking audits to monitor knowledge and the management of such clinical cases. There is a mandated sepsis assessment tool within the initial paediatric triage form on the EPR (Electronic Patient Record) that has been implemented to support the assessment and recognition of a child with sepsis. This tool works in conjunction with the Manchester Triage System tool and local sepsis guidelines. “A child reattending the emergency department will now be seen by the next available doctor, rather than waiting for a paediatrician to become available”. A pathway for children who reattend the emergency department policy has been implemented across Royal Free London Hospital Group. 1 www.royalfree.nhs.uk , Chair , Group Chief Executive “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”. The Royal Free Hospital Paediatric ED has delivered simulation teaching to ED nursing and clinical staff about the management of neurodiverse children. The Royal Free London Paediatric Emergency Departments have distraction kits to support children and families during clinical assessments. Two areas were noted to benefit from further consideration by the Trust. 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”. The Trust has ratified and disseminated an updated guideline for recording and escalating physiological observations in children and young people. This includes guidance for staff that the inability to obtain observations should be considered and escalated in the same way as abnormal observations. In addition, the Trust will be implementing the new national PEWS (Paediatric Early Warning Score) that has been mandated by NHSE as well as the updated paediatric sepsis bundle of care and alerts system. This is being integrated into the EPR and there will be a programme of staff training. 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 Trust can confirm that for patients who reattend an icon is visible next to the patients name on EPR indicating previous attendances within 30 days. The Trust is running refresher training on identifying these icons, and this is covered at the digital training induction for all new medical staff. 2 www.royalfree.nhs.uk , Chair , Group Chief Executive The Trust is committed to ensuring that the lessons are learned from Daniel’s tragic death and to continue to identify opportunities to improve patient safety. The Trust will be monitoring the adherence to these ongoing improvement plans. Yours sincerely Medical Director, Barnet Hospital Medical Director, Royal Free Hospital Royal Free London Group NHS Trust Royal Free London Group NHS Trust Hospital Trust 3 www.royalfree.nhs.uk , Chair , Group Chief Executive
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