The death of boy Regan Smith from Felixstowe could have been avoided

Regan Smith was 11 years old when he died at King's College Hospital in London on January 31 last year.

He had been feeling unwell for the previous 10 days and began breathing “strangely” when he was taken to Ipswich Hospital's emergency department on January 23. It was initially thought that he had laryngitis.

On January 25, an ambulance was called and a finger prick test showed that Regan's blood sugar level was much higher than it should have been.

Regan was taken to the emergency department in Ipswich again – however, the test result was not recorded and therefore not taken into account by the treating physicians. Regan was discharged the same evening.

Regan was admitted to the emergency department again on January 26 before being transferred to Addenbrooke's Hospital in Cambridge.

At this point, he was suffering from severe metabolic acidosis caused by previously undiagnosed diabetes, and his liver was beginning to fail.

Regan's condition continued to deteriorate and he died.

Following an inquest held in July, Suffolk Chief Coroner Nigel Parsley has written to Health and Social Care Secretary Wes Streeting.

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“The information to save Regan's life (his abnormal blood sugar level) was in the possession of the NHS at a time when he could have been given life-saving treatment on January 25, 2023,” Mr Parsley wrote.

“Regan's death was the result of an identifiable single point of failure (the ineffective handoff process) as it resulted in an important and known clinical finding not being available to his treating physicians.”

Mr Parsley explained that the IT systems used by emergency services and hospitals were “not directly compatible”, meaning clinical information was not immediately available to all staff treating patients.

He also noted that there is no national protocol to ensure that basic observations are handed over by emergency medical services personnel and their receipt is acknowledged by emergency department staff.

Mr Parsley called on the Health Secretary to take action to prevent future deaths. Mr Streeting must respond by September 18.