A coroner has called for new children's care protocols to be rolled out in Northern Ireland's hospitals after a health trust missed two red flag opportunities that could have saved a 10-year-old boy's life.
Patrick McGurgan said he wants assurances from all health care trusts that a new system for managing fainting, known medically as syncope, has been implemented in emergency departments.
The coroner made the comments at an inquest into the death of Bradley Logan, who collapsed while enjoying a day out with his family in Co Down.
The schoolboy, from Lisburn, died from a rare heart condition called catecholaminergic polymorphic ventricular tachycardia (CPVT) as he played at a funfair in Newcastle in August, 2015.
Belfast Coroner's Court heard that he had collapsed twice in the months leading up to his death and was taken to the Royal Victoria Hospital on both occasions. However, doctors were unable to detect the condition.
Paediatric cardiologist Dr Karen McLeod gave independent expert evidence during the second day of the youngster's inquest.
The specialist's report stated that Bradley had the first episode during a school sports day after he had completed a sprint race in June. The child, a pupil at Harmony Hill Primary School and a grandson of former Linfield captain and manager Eric Bowyer, was unresponsive for almost two minutes.
His parents Mark and Kylie attended the RVH where he underwent a neurological examination and ECG test, which came back as normal.
Dr McLeod noted that there was no follow-up appointment arranged and his parents were told he could continue with his active lifestyle.
However, almost two months later Bradley collapsed while running to a friend's house and he was taken back to RVH - but the same tests were unable to determine the cause.
Dr McLeod said that CPVT is a genetic condition and that episodes are in response to exercise or emotional distress.
She told the court that there were two missed opportunities to investigate the cause of Bradley collapsing.
"It was a significant event and there were no established protocols to manage syncope in RVH children's ward," she said.
The cardiac specialist added that there had been "warning bells" alerting medical staff to a further serious condition.
She added that an exercise stress test is used to diagnose the condition and that emergency departments should have 24-hour access to this facility.
"It (his death) might have been prevented," she said.
"The key to this is the child's history. Any red flags - even if the ECG is normal - should be investigated further and he should have been referred to paediatric cardiology."
She said that the advice given to the family that he could continue with his exercise was "not appropriate".
She added that if he had been diagnosed with CPVT after the first episode then his death may have been prevented.
The court heard that a flow chart is now in place at the RVH that raises red flags on presentation of certain symptoms, including collapsing after exercise.
Mr McGurgan said he wants to be assured that these protocols are in place across all hospitals in Northern Ireland.
In his findings he stated that the two previous episodes were red flags and these represented "loss of opportunities" in the care of Bradley.
"If (the diagnosis) had been made on either occasion and appropriate treatment given, then the outcome for the deceased would have been different.
"A protocol has been established to monitor syncope. The absence of this represented further missed opportunities to detect his condition."
In a statement, the family said: "Words cannot express how difficult the last two years have been for our family. We miss Bradley every day.
"Unfortunately, two very clear opportunities were missed by the Belfast Trust to diagnose and treat Bradley's condition.
"We now know that on either occasion a simple treadmill test would have identified his condition and would almost certainly have meant that he would still be with us today.
"While we acknowledge the pressure of the hospital staff were under on each of the previous occasions we brought Bradley to the ED, it is quite clear that there was a lack of understanding that collapse associated with exercise was a red flag sign to indicate a possible cardiac cause such as CPVT which should have resulted in Bradley's immediate referral to paediatric cardiac services.
"We do not want other families to suffer as we have."