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.

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.

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.

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

Via email Royal Free London Hospital Group, Pond Street, London NW3 2QG Phone: 020 7794 0500

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“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.

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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.