Doctors missed 11 opportunities to treat a 9-year-old chess champion in the months before he died of chronic asthma, an inquest heard.
Michael Uriely, who was one of the UK's brightest prospects in the game, was taken to the Royal Free Hospital in London twice in the days before his death after he suffered violent coughing and vomiting fits which left him struggling to breathe, the Daily Telegraph reports.
The national chess champion, from St John's Wood, north-west London, died on August 25, 2015, five days after being discharged from the hospital for the second time.
In the months before his death the Westminster Under School pupil was also seen by NHS GPs, as well as having private doctor appointments.
Michael's mother Ayelet Uriely said in a statement that she was "devastated beyond words" about the loss of her son, who she described as "highly gifted".
Westminster Coroner's Court heard that there were chances to treat Michael in the months before his death.
While dealing with Uriely's statement to the inquest, Coroner Dr Shirley Radcliffe said: "There was 11 opportunities within seven months to appropriately test, diagnose and treat him."
The inquest heard Uriely "felt strongly" that her son was denied basic care. As early as February that year, Uriely asked a doctor about the chances of her son dying as she felt his condition was deteriorating.
Uriely said Michael's father Roy took their son out of the room and she asked the doctor about "the likelihood of death".
She said he responded to her by saying: "What are you talking about?" She told the inquest he said that Michael was "not in this category".
Uriely told the inquest she made requests for Michael to be referred to an asthma clinic as well as Great Ormond Street Hospital, but these requests did not materialise before his death.
She said she was told on one occasion that Michael's condition "didn't require it".
Michael was admitted to the Royal Free Hospital on August 18 and discharged at 8pm the same day.
He was readmitted on August 19 and sent home again the following day.
On August 18, Uriely said she thought he was having the worst asthma attack she had ever seen him having.
But she said she was told: "You don't really need to be here. You should go home."
She told the inquest: "I said: 'I can't go without you doing some sort of test."'
Uriely said they were told "something like we were wasting their time", and that Michael would grow out of asthma.
The child was brought back to the hospital in the early hours of August 19, and by this stage was having violent bouts of vomiting as well as a bloated chest.
The inquest heard he was told that he was "hysterical"and not having an asthma attack.
Uriely was told he was being discharged that afternoon but she said she told staff: "I am scared my son will die tonight".
She also said Michael himself said he was "afraid to die", adding that he was "not the kind of person to say something like that".
Uriely told her son: "Mummy's here." She told the inquest: "I said: 'I'd never let anything bad happen to you."' She said she spoke to staff about the "worst case scenario" but was told she was on a "wild goose chase".
There was no improvement in Michael's condition on August 21, the inquest heard.
Uriely made an appointment with Dr Aisha Laskor, believing that her son had been prematurely and inappropriately discharged from hospital.
She felt the prospect of leaving him untreated for the weekend was "frightening" and felt that at this stage it was "imperative" that the referrals she had requested were sorted.
The inquest heard that Laskor expressed shock that the hospital had failed to treat Michael - but the two women disagree about what was said during the appointment.
"Your recollection is completely different," the coroner said.
Laskor said she was "concerned enough to consider calling for an ambulance", but decided not to send him to hospital.
She said her "gut instinct" was to send him back to hospital, but she said Uriely told her he was better since he was discharged - something Uriely says is untrue.
The doctor said she told the Urielys to stay in the waiting room for 20 to 30 minutes after the appointment so that if they needed to see her again they could do so.
Representing the Uriely family, Adam Korn put it to Laskor: "It's not true, is it, that Uriely said Michael had got better?" He suggested she was saying that to "justify" her decision to send him home.
Later in her evidence, a tearful Laskor said: "I was still questioning my decision that evening".
Asked if Uriely appeared to be "desperate", the doctor said: "I would have to say that no, she did not appear desperate".
Michael, who played for Barnet Knights Chess Club, died on August 25 after he collapsed in the early hours and never regained consciousness.
At the time of his death he had been competing in the Mindsports Olympiad, an international multi-disciplined competition which includes chess.
A memorial chess tournament was held for Michael in April last year and December's Super Rapidplay at the London Chess Classic 2016 was also held in memory of him.