A sheriff has ruled that the death of a Scots boy could have been avoided if vital information on his medical condition had been shared between his GP and NHS 24.
Leylan Forte, 4, died from dehydration, gastroenteritis and norovirus in an ambulance outside his home in Montrose, Angus.
The youngster suffered from cerebral palsy, suspected autism, an eating disorder and wasn't able to communicate.
In April 2015, Leylan fell seriously ill. His parents called NHS 24 but said they were repeatedly told a doctor would not be sent out.
Dr Monica Ireland later attended the family's home but Leylan died in an ambulance as it prepared to take him to hospital.
His parents Leanne Smith and Wayne Forte insisted poor advice given by NHS 24 contributed to his death and threatened to sue.
A fatal accident inquiry at Dundee Sheriff Court has ruled Leylan could have survived if his medical needs had been shared in a Key Information Summary (KIS).
It also found a telephone assessment with NHS Tayside Out of Hours service or a home visit was a precaution which could have 'reasonably' been taken by NHS 24.
Sheriff Jillian Martin-Brown also blasted delays into the probe which was held because of 'serious public concern' with the case.
NHS 24 nurse Donald Corbett told the probe he would have ordered an emergency ambulance had he been aware of all of Leylan's circumstances.
In a written ruling, the sheriff said: "All witnesses were agreed that it would have been very helpful to have included information about the deceased's low BMI and parental vulnerabilities in the KIS.
"In light of Nurse Corbett's evidence that if he knew this additional information, then he would have arranged for an emergency ambulance, combined with Dr Chris Kidson's opinion that if the deceased been transferred immediately to hospital for definitive treatment, he would likely have made a full recovery.
"I am of the view that the use of the Key Information Summary of the Emergency Care Summary by the deceased's GP practice to note his low BMI and parental vulnerabilities might have avoided the deceased's death.
"Despite guidance indicating that it was possible to create a KIS for any patient, the evidence of all three general practitioners who gave evidence to the inquiry was that this was a counsel of perfection rather than standard practice back in 2015.
"I am pleased to hear that greater use is being made of the KIS after the Covid-19 pandemic.
"However, in light of the lessons learned from this inquiry, I think it would be useful to recommend that GP practices should make greater use of Key Information Summaries on Emergency Care Summaries where appropriate to improve information sharing between GP practices and NHS 24."
Sheriff Martin-Brown said it was 'difficult to understand' how the public interest was served by having an inquiry six years following a death.
The sheriff added: "Some four years passed before notice that an inquiry was to be held was given by the procurator fiscal in September 2019.
"Despite the passage of time, it was apparent at the first preliminary hearing in November 2019 that the Crown were not properly prepared and had still not obtained the deceased's full GP records.
"In addition, I required to highlight to the procurator fiscal that commentary by experts outwith their area of expertise would not assist the inquiry.
"Despite several preliminary hearings, the Crown failed to comply with various court deadlines, evidence and lodging of affidavits and productions.
A Crown Office and Procurator Fiscal Service (COPFS) spokesman said: "We note the determination and would like to express our sincere condolences to Leylan's family.
"COPFS has increased the resources available to its death investigations teams and changed working practices with a focus on progressing older cases
"These measures are delivering a significant improvement in the service delivered by the procurator fiscal in this important area of work."
Dr Laura Ryan, NHS 24's Medical Director said: "We remain very sorry that Leylan died in 2015 and once again offer our deepest condolences to his father and his family.
"We welcome the determination from Sheriff Martin-Brown and will take time to consider it in detail. NHS 24 will embed any required improvements and changes, based on identified learning or recommendations in the report.
"NHS 24 continuously reviews its services to ensure all patients, including children, are provided with the safest, effective and most person-centred care.
"This is supported by frequent scrutiny of current national clinical practice, evidence based guidelines, and collaboration with expert advisors where that is needed.
"In addition, more broadly, we know GP practices frequently use the Key Information Summary for individual patients, when it is judged that certain information would support clinical services.
"For NHS 24 clinicians, this extra information supports the right outcome for those people who may need a tailored response, including those with complex needs."
NHS Tayside were approached for comment.
