An "inadequate" handover meant staff were not able to "join the dots" to diagnose an 11-year-old boy with diabetes, a coroner has said.

The senior coroner for Suffolk has said following evidence heard into the death of Regan Smith from Felixstowe he will write to the Secretary of State calling for changes to better guidance around handovers.

Senior Coroner for Suffolk Nigel Parsley delivered a narrative conclusion following a two day inquest into Regan's death.

In the 10 days leading up to his death, Regan had begun to breathe “strangely”. He had previously visited Ipswich Hospital’s A&E department with his father on January 23, and again on January 25, having been taken to hospital by ambulance. A nurse practitioner had seen him the previous day and diagnosed him with laryngitis.

A blood glucose test taken by paramedics on January 25 showed that his levels were high, at 12.5 millimoles per litre.

However, the court heard that information was not passed on when he arrived at hospital.

Mr Parsley found that Regan had died as the result of an untreated natural cause, following a “missed opportunity” to provide treatment, which should have happened as a result of the glucose reading on January 25.

“Had clinicians known about the glucose level, they may have joined the dots. But, as far as they were aware, his glucose was normal,” Mr Parsley said.

He found that it was more likely than not that pressure on the department had been a factor in an “inadequate” handover process, which in turn had prevented a diagnosis.

The court previously heard that Regan had developed diabetic ketoacidosis (DKA). This is a serious condition that can happen in people with diabetes, when a lack of insulin causes harmful substances called ketones to build up in the blood. The condition is known to be life-threatening and requires urgent treatment in hospital.

On Monday, the junior paediatric sister, Nurse Julia Day-Stewart, described the handover she had received from paramedic Joseph Piper as “muddled”, “confusing” and “jumbled”. She said she was initially unclear as to why Regan had been brought to hospital, and queried whether his laboured breathing was due to anxiety.

It was also noted that the handover document incorrectly described Regan’s blood glucose level as “normal”.

The court heard that the hospital was exceptionally busy, with staff unable to take their breaks. When Regan was seen by a clinical, it was in a hospital corridor.

Regan was discharged a few hours later.

Regan collapsed at home on January 26 and was blue-lighted to hospital. He was diagnosed with DKA, and transferred to Addenbrookes Hospital the same day. On January 29, he was moved to King’s College Hospital to be cared for by hepatology specialists, as his liver was beginning to fail.

He died two days later.

Professor Akash Deep of King’s College Hospital told the court that DKA does not specifically cause liver failure, but there are rare instances when a patient presents with diabetes for the first time, and also has an underlying issue with their liver. The two conditions then “exacerbate” each other.

This was the case with Regan, he explained, who had steatosis of the liver, which meant he was hypersensitive to levels of sugar in his blood.

Professor Deep gave Regan’s cause of death as multiorgan failure, having been caused by liver failure and DKA.

Mr Parsley heard evidence from Ipswich Hospital that steps have been taken to ensure that staff are aware that a patient has been transported to hospital by ambulance.

A new electronic record system is in the process of being finalised and should become effective from early next year, and steps will be taken to ensure that patient records are read by staff.

The court also heard that in the 12 months after Regan’s death, a diabetes nurse specialist delivered monthly one-hour diabetes training sessions to staff at Ipswich Hospital.

However, the court also heard that there is currently no guidance issued but the National institute for Health and Care Excellence (NICE) on how to carry out efficient handovers between ambulance workers and hospital staff.

Mr Parsley said he would be writing to Health Secretary Wes Streeting to relay these concerns.

A system which relies on the verbal handover between staff places an “unnecessary burden of responsibility” on those involved, Mr Parsley said, and relies on no member of staff ever making a mistake.

Mr Parsley ended proceedings by thanking Regan’s family for the “quiet dignity” they had displayed throughout the process.