A key chance to save the life of a four-year-old boy who died from sepsis after being taken to hospital four times in a week was missed, a coroner has said.

Daniel Klosi, who had autism, died from sepsis at the Royal Free Hospital in the early hours of April 2 last year.

The four-year-old boy, from Kentish Town, had been taken to the hospital emergency department four times in a week, including twice in one day, by his anxious parents.

Senior coroner Mary Hassell said Daniel’s illness had been ongoing for a week by his third trip to the hospital but at this point his medical records were not looked at properly.

A chance to give antibiotics that would have saved his life was also missed, she added.

The coroner, sitting at Poplar Coroners Court yesterday (August 14) said she had given “full consideration” as to whether there had been neglect in Daniel’s case, but decided it was not appropriate.

Dr Tim Wickham, a consultant paediatrician at the Royal Free NHS Foundation Trust who led an investigation into the incident, told the inquest: “I think we failed him in that we did not recognise how ill he was.”

He added: “He was the illest patient throughout the entire evening. He was going into septic shock, and we did not recognise it.”

The coroner said Daniel was brought to the emergency department four times and was not admitted until the final occasion when he “was acutely septic”.

She described the first and second discharges as “reasonable and understandable”, but that by the fourth occasion Daniel had “begun the process of sepsis”.

She added: “I do not know whether antibiotics on that fourth admission would have saved him.”

The coroner said “it seems to me that Daniel could have been helped” on that third visit.

She also explained that Daniel came in with an “atypical presentation of sepsis”, and there was a “lack of understanding” of how to view the needs of a neurodivergent child.

Dr Wickham said changes have been made since Daniel’s death. Someone who reattends the hospital will now be seen by the next available doctor.

A Royal Free London spokesperson said: “This is a desperately sad case and we are deeply sorry that Daniel died while under our care. We would like to share our heartfelt condolences with his family and loved ones.

"Following a thorough investigation, we identified a number of areas for improvement, and measures were taken to immediately address these.

“This included…how we care for children with learning disabilities; and the importance of listening to parents and carers when they raise concerns.

"We take the coroner’s findings seriously and will carefully review all the issues identified to try to ensure a tragedy like this never happens again.”

Reporting by PA.