An inquest jury in Ipswich has criticised medical staff for failing to spot the signs of deadly meningitis in six-year-old Oliver Hall from Halesworth.
The youngster died of the disease at the James Paget University Hospital on October 24, 2017, just hours after he was assessed by a trainee doctor and senior GP.
He was taken to Cutlers Hill Surgery in Halesworth by ambulance after his mother Georgie called the emergency 111 number.
Today a jury at his inquest, held at Suffolk Coroner's Court at Beacon House in Ipswich, reached a damning conclusion.
They found he died of natural causes contributed to by neglect.
"Oliver's death was caused by neglect, by a gross failure to provide medical treatment," they said.
Failures to communicate, failures to carry out full examinations and failures to carry out sufficient observations were highlighted during the five-day inquest.
Suffolk senior coroner Nigel Parsley made a series of recommendations to prevent future deaths.
His area of greatest concern was the transfer of information from 111 to 999 numbers.
The inquest heard the 111 operator had identified a possibility of septicaemia but this information was not passed on to the paramedic crew or the GPs who examined Ollie.
"The current system failed to get that information to either the paramedics and subsequently the GPs who had to make the clinical decisions in Ollie's treatment," he said.
"This cannot be right."
Since his death, Ollie's parents Georgie and Bryan have been campaigning to raise awareness of meningitis.
They want the government to roll out the vaccine to older children on the NHS.
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