Parents of a child who suffered an asthma attack at school and died in hospital a few hours later have expressed their anger at the "complete absence of common sense" which led to his death.
Five members of staff at Offerton High School in Stockport have since been suspended following the damming findings of the inquest into Sam Linton's death.
While the 11-year-old struggled for breath, a teacher made him wait in the corridor. Doctors later said he could have been saved had this valuable time not been lost.
An inquest jury ruled that Sam died of "died of natural causes, significantly contributed to by neglect, both individually and on a systemic level".
Sam's mother, Karen Linton, said, "Samuel was a wonderful son and his loss has been devastating. The inquest highlighted what happened at school that day and the thought that his death may have been prevented is too much to bear,"
The inquest into Sam's death heard how two schoolchildren had found Sam suffering breathing difficulties in the corridor where his class tutor, Janet Ford, had made him wait.
When one of the children went to see Ms. Ford, she told them to go away because she was in a meeting, adding "I know Sam's there. He will have to wait."
Ms Ford denied the children's version of events, but admitted that "in hindsight I would have done things differently."
Coroner John Pollard said he had found Ms Ford's responses 'unconvincing'.
The case exposed weaknesses in the school's policy for dealing with asthma and a spokesman for Stockport council said, "We are now considering the inquest verdict and the recommendations of the coroner as a matter of urgency, and will take all necessary actions identified and needed."
But for Sam's family, this provides little comfort. Speaking on behalf of the family, their lawyer Jonathan Betts said, "The fact that no one called an ambulance is astounding and deeply troubling ... When you send your child to school you believe they will be looked after and cared for,"
Do schools take children's medical conditions seriously? Do you feel your child is safe at school?