Daniel Klosi
16 Aug 2024 · Coroner Mary Hassell · Inner North London
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed or missing clinical observations
“It was difficult for the nursing staff to obtain [the deceased]'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 [the deceased] 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”
2. lack of repeat presentation tracking
“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.”
Linked reports
Closely relatedConfidence 0.92 · high
This report
“It was difficult for the nursing staff to obtain [the deceased]'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 [the deceased] did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.”
Later report
“The lack of serial nursing observations was a fundamental omission from [the deceased]'s care.”
Closely relatedConfidence 0.87 · high
This report
“It was difficult for the nursing staff to obtain [the deceased]'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 [the deceased] did not have a full set of observations for over four hours”
Later report
“Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded.”
Responses
2024-0462-Response-from-RCEM.pdf ↗· Royal Free Hospital
Stated action
“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.”
2024-0462-Response-from-RCPCH.pdf ↗· Royal Free Hospital
Stated action · 2025
“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”
Stated action
“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”
Stated action
“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”
2024-0462-Response-from-Royal-Free-London-Hospital.pdf ↗· Royal Free Hospital
Stated action
“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.”
Stated action
“A pathway for children who reattend the emergency department policy has been implemented across Royal Free London Hospital Group.”
Stated action
“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.”
Daniel-Klosi-narrative.pdf ↗· Royal Free Hospital
Stated action
“I intend to make a prevention of future deaths report”