A young boy bled to death in hospital over a weekend due to a severe lack of communication between doctors, a coroner has ruled.
Two-year-old Tharun Umashankar died from bleeding of the stomach lining which was probably caused by his intolerance to milk.
He was rushed into Sheffield Children's Hospital and despite suffering a previous large internal bleed, was not earmarked for an endoscopy to look at his digestive system until the next day.
Independent expert Dr David Crabbe, a paediatric surgeon, said the procedure would have found the bleeding and Tharun could have had an operation that day to remove part of his stomach - a procedure which would have saved him.
He told the Sheffield inquest: "What was a complete failure was the lack of collaboration between surgeons and gastro-enterologists. Closer teamwork would have resulted in a different outcome."
Recording a narrative verdict, Sheffield Cornoner Chris Dories said: "On the basis of expert opinion, there was a a failure to plan and/or a failure to communicate about a child who was known to be at serious risk.
"While it remains unclear whether requested communication to the gastro-enterologist at the first sign of deterioration would have saved Tharun's life, it is very clear that it may have done so.
"However, endoscopy and surgery on the previous day would likely have saved Tharun's life, but such was a matter of judgment rather than specific failure."
Tharun had endured three endoscopies at the hospital in the previous fortnight after vomiting blood and suffering stomach pain, but was thought well enough to be discharged on Friday, July 9, 2010.
Consultant paediatric gastro-enterologist Dr David Campbell, who was in overall charge, although off duty that weekend, said he left instructions to be called if the boy had a serious bleed again.
Tharun was readmitted on the Saturday, after mother Sentamil, 38, became worried, but paediatric registrar Dr Tafadzwa Makaya told the inquest she had not been told to alert Dr Campbell.
However, despite a blood transfusion, Tharun failed to respond and he died at 9am on the Sunday.
The family are now taking civil action for damages.
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