A mother today called for improvements to NHS staff training and systems after doctors failed on three occasions to identify an infection which killed her one-year-old son.
Jodie Conlay was speaking out after a coroner delivered a narrative verdict saying that "had appropriate treatment been instigated on any of these three occasions it is likely Lewis would have survived".
Lewis Mullins died just over a year ago, nine days after his first birthday, after suffering streptococcal pneumonia which he developed after having chickenpox.
He was sent home from an NHS walk-in centre once and Rotherham Hospital twice in the three days prior to his death as doctors failed to spot his condition, lawyers representing the family said.
Parents Ms Conlay, 28, and Andrew Mullins, 32, from Maltby, have been left devastated by the death.
Ms Conlay said: "I still can't believe that Lewis is no longer with us. He was such a content baby, a real happy chappie.
"We have pictures from his first birthday just days before he became ill.
"His big sister keeps telling me she misses her little brother. It has hit both myself and Andrew very hard.
"Hearing that the treatment given to Lewis could have been different and could have saved his life was completely soul destroying.
"I just hope now that changes can be made, and more notice taken of parents' concerns, to try and prevent others from having to go through the heartache that we have."
Medical law experts at Irwin Mitchell representing the family, today joined Lewis' parents in calling for improved procedures and training.
The law firm said Lewis was initially treated for severe chickenpox at an NHS walk in centre on March 30 2011 where he had presented with chickenpox spots and a high temperature.
A doctor sent him home with a prescription for acyclovir, an antiviral drug, but he was rushed by ambulance to A&E at Rotherham Hospital the following day after developing a new rash, difficulty breathing, as well as a persistent very high fever.
He was discharged as doctors thought he was suffering from an allergic reaction to the acyclovir, but he had to visit hospital again on April 1 as his condition deteriorated further, with fever, spreading rash and difficulty breathing.
He was seen by doctors but again discharged, on this occasion without even being seen by a paediatric specialist, the law firm said.
His condition deteriorated further still the next morning. He stopped breathing in his father's arms and was rushed back to hospital by ambulance. Unfortunately the doctors were not able to revive him and he died. Basic blood tests or a chest x-ray in order to rule out bacterial infection were never considered by the doctors who saw Lewis.
At an inquest at Rotherham Magistrate's Court Coroner Nicola Mundy delivered a narrative verdict and said she would write to the relevant people with recommendations regarding the use of documentation at the walk in centre.
The inquest discovered procedural problems had impacted upon the youngster's care.
Heather Kolar, a medical law specialist at Irwin Mitchell, said: "There were a number of occasions during Lewis' treatment that medical staff could and should have done more to identify and treat his condition. He was just one year old and clearly very ill. Lewis needed the utmost care when he was at his most vulnerable but tragically, on this occasion the standard of care was not good enough.
"The medical evidence suggests that had Lewis been given appropriate antibiotics the outcome would have been different. Medical staff should have recognised that his illness was more serious and carried out simple blood tests and an x-ray to find out what else was wrong.
"No-one can possibly imagine what Jodie and Andrew have been through, losing their son just days after his first birthday. Nothing can ever bring Lewis back and they will never get over that. But the one thing they are determined to do is to get assurances from the hospital that they have improved their training to ensure that no other parent ever has to go through what they have."