A coroner has said not giving a blood test to a boy with an undiagnosed rare illness was “a failure to provide basic medical care”.
Callum Cartlidge, aged eight, died after suffering a cardiac arrest at home in Redditch, Worcestershire, on 3 March 2017.
He was discharged from Worcestershire Royal Hospital the previous day with a diagnosis of gastroenteritis.
The coroner said death would have been prevented if a blood test was done.
Callum had been suffering an Addisonian crisis, linked to undiagnosed Addison’s Disease.
A medical expert told the inquest the test would have identified Callum’s rare disease which is caused by damage to the adrenal glands and reduces hormone levels in the body.
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Recording a narrative verdict, assistant coroner David Reid said while not carrying out the blood test was a “serious failing”, it was not a gross failing and he could not record a verdict of neglect.
Worcestershire Coroner’s Court heard if the illness had been identified on 2 March, Callum would have survived.
Callum, who was described as usually a fun and “cheeky chappie” was “lethargic and yellow” and regularly off school in the months before his death.
During the five-day hearing, the court was told how Callum had a 23-minute ambulance journey to Worcester hospital the day he died, rather than to the Alexandra Hospital, three minutes away, which stopped admitting children to A&E in 2016.
However, Mr Reid – who heard evidence from a paediatric emergency consultant – said he did not think it had been a factor in the boy’s death.
Dr Andrew Short, the divisional medical director for Worcestershire Acute Hospitals NHS Trust, expressed their “deepest condolences” to the family and said despite their “best intentions, the outcome is not what we anticipated.”
He added: “The coroner recognised that we have carried out our own thorough review of what happened to Callum to make sure that we learn from his death for the benefit of patients in the future.”