Three-year-old John Andrew Kirkham was in an ambulance and on the way to hospital when he suffered a cardiac arrest and could not be revived.
His death came after he had been seen by both hospital and GP staff in the days leading up to his death.
James Newman, assistant coroner for Derbyshire, summed up the five-day inquest today (Friday) at Chesterfield Coroner’s Court.
He said: “I find that on the balance of probability if antibiotics had been prescribed, John’s condition would not have deteriorated as catastrophically as it did and his death would have been avoided.”
The inquest heard that John had been admitted to Stepping Hill Hospital’s accident and emergency department and his heart rate, temperature and respiratory levels were all high.
He was due to be discharged, but his condition deteriorated and he was admitted to the pediatric ward where observations were only completed once.
John was examined by doctor Michael Cocker, a trained GP who was six months into his specialist field, but no formal observations were conducted or any antibiotics given before he left, the inquest was told.
“There were significant opportunities to observe and monitor John before he was discharged,” said Mr Newman. “A more thorough and clinical observation should have taken place.”
After leaving hospital he slept in bed with his mother, Joanne Kirkham, and the next day he was described as less interested and half-hearted approach when he visited his paternal grandmother’s farm.
The inquest heard how on the day of John’s death, Joanne rang Elmwood Medical Centre and could not get an emergency appointment, securing one later in the day.
“I have great deal of sympathy with Mrs Kirkham who rang at 8.50am on a Monday but there were no more emergency slots left,” said Mr Newman.
It was at the doctor’s surgery that doctor Ian Maclure became concerned about John’s condition and rang for an ambulance to take him to Macclesfield District Hospital. Life support was needed in the surgery before he made the journey.
After suffering a cardiac arrest and vomiting in the ambulance, the coroner described as “valiant” the efforts to save the youngster.
The post mortem concluded John died from acute streptococcus pyogenes, a secondary infection after suffering from chicken pox due to a weakened immune system.
Mr Newman said: “Streptococcus pyogenes is a rare condition, but from what evidence I have heard this complication should be known about.”
In closing, he commended the Kirkham family for being brave as they sat through four days of evidence: “I can’t imagine what you have been through. I wish I could tell you the conclusion of this inquest will wave a magic wand and make it better, but it does close doors that have been open since John’s death.”
Mr Newman recorded a verdict of natural causes.