A 14-month old boy who died after swallowing a battery might have survived if medical staff had not neglected important aspects of his care, an inquest heard.
Wsam Noorwali died from internal bleeding on August 19 last year, nine hours after being taken to Leicester Royal Infirmary.
Coroner Catherine Mason said "omissions" and "neglect" in the toddler's care meant the problem was not identified until it was too late.
"Due to neglect in some important aspects of his care, Wsam was not resuscitated as quickly as he could and should have been," she said.
Recording a narrative verdict at the end of an inquest at Leicester Town Hall yesterday, she criticised decisions "made on incomplete and out of date data" – and the absence of a senior paediatric surgeon at the hospital site as Wsam's condition deteriorated during the night.
The battery, described as the size of a two-pence piece, had corroded an artery wall, causing the fatal haemorrhage.
But it was not until a postmortem examination that the battery was found in the boy's stomach.
Parents Ammar Noorwali and Fatima Nasralla said they found Wsam vomiting blood at the family home in Hamilton, Leicester.
In hospital, he was first assessed in accident and emergency at about 10.30pm, before being moved to the hospital's children's ward.
His condition improved at first, but he suffered further bouts of vomiting blood at 2.05am and 4.30am.
With his condition deteriorating, Wsam was transferred to the children's intensive care unit and had two blood transfusions.
But by that point doctors said he was too weak for emergency surgery.
Wsam suffered a heart attack and died an hour later, just after 7am.
Following the second bout of vomiting blood at 2.05am, an urgent endoscopy should have been carried out to diagnose the underlying cause, the inquest heard.
This was the view expressed by paediatric registrar Sandip Ghosh to paediatric surgical registrar Jude Okoye.
However, after consulting with on-call paediatric surgeon Bharat More, who was on call at home, they decided to continue resuscitating and monitoring Wsam until he was stable enough to undergo the procedure.
The inquest heard this decision was based on "vital signs" taken at 1.20am – before the crucial second bleed – which also revealed "abnormal" blood results.
Nursing staff should have taken and recorded Wsam's vital signs every 15 minutes, the court heard.
The inquest also heard there was no evidence of a management plan to suggest Dr More, who arrived at the hospital after 5.30am, intended to carry out an endoscopy.
It also emerged that in any case, he did not have the experience recommended by professional bodies to carry out the procedure.
Ms Mason said although Wsam may still have died, there was a "missed opportunity" to treat him sooner which could have potentially saved his life.
She said she would be writing to Leicester's hospitals and national medical profession bodies due to her "serious" concerns.
Speaking after the verdict, Mr Noorwali said the family was "devastated" by their loss.
"My wife Fatima and I miss Wsam terribly," he said.
"Our whole family is devastated."
Mr Noorwali described their son's treatment as "appalling".
"I still struggle to deal with the way in which Wsam was treated before he died, and it makes me angry and upset to think about it," he said.
Matthew Olner, clinical negligence specialist at Nelsons Solicitors, Leicester, which is acting on behalf of the family, said the parents were considering suing Leicester's hospitals.
Beverly Collett, associate medical director at Leicester's Hospitals, said: "This was a very unusual and tragic case and our condolences go to Wsam's parents for their loss."
She said it was now the policy in Leicester to X-ray any child less than two years of age who is vomiting blood – and a new "standard operating procedure" was in place for dealing with similar cases. "We take on board the comments made by the coroner," she said.
!['Neglect in aspects of care' led to death of toddler Wsam Noorwal who swallowed battery]( "'Neglect in aspects of care' led to death of toddler Wsam Noorwal who swallowed battery")
