A little boy who went into hospital for heart surgery suffered cardiac arrest within a week and died partly due to Bank Holiday staff shortages, according to a report.
Luke Jenkins, seven, was expected to make a full recovery after his successful corrective surgery at Bristol Children's Hospital.
His grieving parents Stephen Jenkins, 30, and wife Faye, 27, of St Mellons, Cardiff, south Wales, were stunned by the contents of a report into the tragedy.
Put together by an investigative team at University Hospitals Bristol NHS Foundation Trust, what it has identified amounts to a tragic catalogue of avoidable human errors which combined with fatal consequences for Luke on April 6.
Junior nursing staff lost vital time because they did not know where resuscitation equipment on Ward 32, where Luke was placed, was kept and the emergency team was also unfamiliar with the equipment because cardiac arrest was rare in the ward environment.
The fact that Luke suffered a cardiac arrest on Good Friday meant that the duty surgeon was at home when he collapsed and had to be urgently called in to attend hospital.
While staff numbers on the ward was set according to official guidance, low staff levels had been a problem for at least two years. "A risk assessment identifying low and unsafe nurse staffing and high dependency patient acuity issues was developed following a high-risk incident in October 2010 remains outstanding," the report states.
Other worrying factors include the resetting of potentially vital alarms on Luke's condition monitoring equipment after his arrival on Ward 32, and an assertion that Luke underwent an x-ray the day before his death is questioned in a letter sent in reply to the report.
"If he had had an X-ray they would have found what was wrong with him and he would still be here now," said an emotional Mr Jenkins. "But we were with him all day and we know that it never happened."
He said that the family intended to fight on until the full truth was revealed. "We have written saying that we are not happy with the report because some of what is in it is not true."