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A Southampton coroner has criticised an NHS out-of-hours service nurse who told a 12-year-old boy's mother she should wait 13 hours to see a GP just days before he died.
Sam Cutler, 12, was probably seriously ill with endocarditis - a bacterial inflammation of the heart lining - and suffering from dehydration and delirium on May 9 last year.
His mother, Linda, had spoken to out-of-hours nurse Gary Richards, who advised she should take her son to the surgery the next morning.
This was despite Mrs Cutler telling Mr Richards her son was confused, running a temperature and had a rare heart condition - symptoms that should have led to him being seen within two to six hours.
Southampton Coroner Keith Wiseman said Mr Richards should have taken "a safety first approach'' to Sam's symptoms.
During a five-day inquest in Southampton, the hearing heard that Sam was taken to his surgery the next morning and saw GP Abdul Shahid, who immediately arranged for him to go to hospital.
The doctor was critical of the advice given by the out-of-hours service because notes he received from it said Sam should have been seen within six hours.
"Perhaps he should have been seen in a walk-in centre. It was entirely their discretion, but I would have looked at the child on the day,'' the doctor said.
Sam, from Southampton, had a congenital heart condition where all his organs were in the opposite position to what they should be.
He had had three major operations in his life and the inquest heard that this had left him with an increased risk of contacting endocarditis - which presents a wide-range of symptoms, including fever and confusion.
He was diagnosed with endocarditis in hospital but on May 17 he died from a sudden clot, which had developed after he was being treated for the infection of his heart and other organs brought on by the infection.
The youngster, who died just three days short of his 13th birthday, had first become ill with vomiting on May 6. Another GP diagnosed gastric flu but by May 9 he had deteriorated - prompting the call to the out-of-hours service.
A comprehensive review by Solent NHS Trust found that Mr Richards actions had "fallen significantly short'' during the telephone conversation with Mrs Cutler.
The report concluded the failure was individual and not organisational.
Mr Richards, a senior nurse, received a formal warning and was told to retrain, the inquest heard.
Recording a verdict of natural causes, Mr Wiseman said that, "on a balance of probability'', Sam's symptoms "must have been present'' when the out-of-hours service spoke to the family on the Sunday evening.
"The extent of further significant deterioration between Sunday evening and the Monday morning is unclear, but obviously the earlier treatment can be given the more chance there must be of the recovery of the patient.
"The extra vulnerability of a child with a significant congenital condition demands a safety first approach.''
Solent NHS Trust chief executive Dr Ros Tolcher said in a statement after the inquest:
"We are very sorry a young life was lost and extend our sincere condolences to his family and friends.
"We will be looking in detail at the coroner's findings to establish how we can make further improvements to our services.
"Steps have already been taken to enhance training for our staff and to obtain specialist paediatric input for calls concerning children.
"It is our aim to consistently provide the very best care possible for people who use our services. We will always work hard to understand what went wrong or where we can improve when we fall short of expectations.''