Doctors missed sepsis in boy aged 4, inquest told

A four-year-old boy who was taken to hospital four times in a week was "probably" septic when he was seen by medical staff in the hours before he died, an inquest heard.

Daniel Klosi died from sepsis at the Royal Free Hospital in Camden, north London, on 2 April 2023, after his parents had taken him to the hospital four times in a week, including twice in one day.

At East London Coroner's Court, Dr Gautham Benoy, who was a trainee GP with little experience in paediatrics, said he could see Daniel was an "unwell child" when he saw him on the evening of 1 April last year, during the fourth hospital visit.

Dr Benoy accepted that Daniel was "probably" septic or "probably at the earliest stages".

During the hearing, at which a number of medical staff gave evidence, coroner Mary Hassell said it might appear that "a child is admitted at 5pm-ish septic, and that isn't recognised until 9.15pm".

Daniel had sunken eyes, cracked lips, looked likely to be severely dehydrated, had abdominal pain and was "quite restless and appeared in distress" when Dr Benoy tried to examine him, the court heard.

Dr Benoy, who said he wanted to get assistance from a consultant, said: "I thought he was definitely a very unwell child and needed further treatment. I thought he needed admission and was at risk of sepsis."

However, he added: "It surprised me how quickly he deteriorated. I did not expect that would happen."

Dr Benoy turned to Daniel's parents as he answered a question on whether it would have been appropriate for him to have spoken to them to try to allay their concerns.

He told them: "I understand. I am sorry for everything you have been through."

Dr Amisha Singh, who works in consultant paediatrics, saw Daniel some time between 21:00 and 21:15 and about 30 minutes after he had been seen by Dr Benoy.

"I did not think there was any indication that the child was septic at that time," she told the inquest.

When asked by the coroner, she agreed that Daniel would have been septic when he was seen by Dr Benoy.

On the possibility of Daniel already being septic on his third visit to the hospital earlier on 1 April, Dr Singh said: "Sepsis can progress very rapidly. I do not know I'm afraid."

She was later asked whether Dr Benoy had made a mistake or if the child's condition had become worse.

"I would say that he got worse," she said.

Daniel's father, Kastriot Klosi, previously remembered his son as a "lively boy" with no health issues other than his autism.

On 26 March 2023, he and Daniel's mother, Lindita Alushi, noticed Daniel 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.

They returned on 30 March, when a doctor and nurse said Daniel had picked up a virus, and that he should "go home and rest", the father's inquest statement said.

The parents called 111 and were booked in for triage at the hospital on 1 April after Daniel "suddenly stopped eating and drinking", and he was seen at about 13:00.

Mr Klosi said he was told Daniel's "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, of Kentish Town, north London, went back at about 16:30 and he started "deteriorating" in front of them, his nose, hands and feet "turning purple" and his lips becoming cracked and blue.

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