A nine-year-old chess prodigy who died from chronic asthma could have been saved if he had not been sent home from hospital days earlier, a coroner has ruled.
Michael Uriely died from an asthma attack on August 25 2015, five days after he was discharged from Hampstead's Royal Free Hospital.
Michael, from St John's Wood, north west London, was repeatedly seen by doctors in the months before his death, including an NHS GP, private paediatrician and hospital staff.
Despite the frantic efforts of his parents, Ayelet and Roy, they all failed to diagnose him with chronic asthma or refer him for the specialist care that could have saved his young life.
Coroner Dr Shirley Radcliffe found that if the Royal Free had kept him in for treatment he might not have died.
She said in her conclusions on Thursday at Westminster Coroner's Court she made a national recommendation to try and prevent future similar deaths.
Seven other children in London have died from asthma since Michael's death, the inquest was told.
Expert respiratory paediatrician Dr Richard Iles said the Westminster Under School pupil's death was preventable and he should have been referred to a specialist.
He said there were a number of clear signs that the care programme was not working months earlier.
Michael was taken to the Royal Free Hospital on August 18 after he suffered violent coughing and vomiting fits which left him struggling to breathe but he was discharged at 8pm the same day.
His parents rushed him back to A&E after he suffered another severe attack during the early hours of the morning on August 19.
He was kept in overnight before being sent home again the following day.
The Royal Free Hospital carried out two internal investigations after Michael's death and concluded that staff failed to diagnose him with chronic asthma and the care he was given was not adequate.
The hospital has since appointed two specialist respiratory clinicians, opened a dedicated asthma clinic and implemented a new strategy for treating children with asthma.
Michael died from an acute asthma attack, the coroner ruled.
Mrs Uriely, 52, said was "devastated beyond words" about the loss of her son, a national chess champion who she described as "highly gifted".
She said before the inquest: “Michael was an extraordinary boy, both in personality and intelligence, who came to us after four gruelling years of fertility treatment.
“He doted on his younger twin sisters, who adored him, and always joined in with their games.
"Now we would just like answers as to why he died.”
He was diagnosed with asthma when he was two-and-a-half years old and began learning how to play chess around six months later, competing at local, regional and then national level as he grew up.
Dr Radcliffe concluded that if Michael had remained in hospital on a high dose of steroids with a referral to a respiratory specialist "it's unlikely he would have died".
She said that by the second attendance at A&E in 24 hours "alarm bells should have begun to ring".
She added that a "totally inadequate history was obtained" after the paediatrician who treated him on the second admission failed to realise he had been there the previous day.
She said: "The opportunity was lost to recognise this as a serious problem - the history and signs were there to be seen and understood.
"But sadly it wasn't recognised and he was discharged essentially on the same treatment he had been on.”
Additional reporting by Press Association