Senior coroner Mary Hassell emphasized, '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.' This pointed to a serious oversight in the recognition of his deteriorating condition, as his complex medical needs related to his autism may not have been adequately addressed.
Dr. Tim Wickham stated, 'I think we failed him in that we did not recognise how ill he was,' underscoring the medical team's failure to identify the severity of Daniel's condition during multiple visits.
The coroner noted, 'I do not know whether antibiotics on that fourth admission would have saved him,' which indicates uncertainty over whether timely intervention could have changed the outcome.
Dr. Wickham acknowledged, 'He was going into septic shock, and we did not recognise it,' highlighting a critical failure in the emergency response to Daniel's severe health decline.
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