Several opportunities were missed by a hospital to diagnose a “wonderful and loving” boy with a rare heart condition which would have prevented his death, an inquest has heard.

Akinwemimo Akinola, known as Alfred, passed away on August 30, 2023, after he had a seizure and went into cardiac arrest.

A two-day inquest was held at Oakwood House, in Maidstone, this week by area coroner Catherine Wood who found failures in the 11-year-old’s care.

The court was told on the day he died Alfred was playing football with two friends off Cross Lane West, in Gravesend, when an argument broke out and he was allegedly punched.

The youngster collapsed to the ground and suffered a seizure prompting the other children to run and get help from adults who started CPR.

The emergency services arrived and Alfred was blue-lighted to Darent Valley Hospital, in Dartford, where he died despite efforts to save his life.

At the time, another boy was arrested, however, Detective Sergeant Kendal Moore told the court he was released and no charges were brought forward.

The court heard Alfred had a history of collapsing and seizures, the first being when he was eight years old in Nigeria, which had become more frequent as he got older.

On September 6 2022, the Whitehill Primary School pupil was taken to the hospital’s paediatric emergency department after he collapsed during lunchtime while playing football.

Giving evidence, speciality registrar Dr Nimrit Sanghera said she assessed the youngster but discharged him as she “did not have any concerns”, concluding he had suffered “a simple faint”.

She told the court she had not been informed of any previous history of collapsing.

On November 10 2022, Alfred was brought into the department again by an ambulance after he had suffered a seizure while queuing to get onto the playground at school.

He was again assessed by Dr Sanghera, who ordered a full clinical investigation including an electrocardiogram (ECG), which records the electrical activity of the heart, as it was the second time he had shown similar symptoms.

Two ECGs were also carried out in the ambulance, and all three were marked as “abnormal” by the machine and showed a prolonged QT interval, meaning the heart’s ventricles took longer than normal to recharge between beats.

However, the court was told that Dr Sanghera signed it off as “normal” before she referred and handed over Alfred’s care to the hospital’s paediatric assessment unit (PAU).

She said: “I was busy and signed it in haste and I did not give it the due care and attention it deserved.”

When questioned by Ms Wood, the clinician said, on reflection, the results were abnormal but added she would have expected them to have been reviewed again by the next doctor.

The court heard the abnormal ECG results were again missed by the PAU medic and Alfred was instead referred to consultant paediatrician Dr Sapna Singh.

Giving evidence, she said she was told the clinical investigations had come back as normal and she did not see the ECG at the time but if she had, she would have recognised it as abnormal.

Dr Singh explained in hindsight she would have worked out the results manually to check the machine’s conclusions were correct, repeated the test and referred Alfred to a specialist cardiologist.

Instead, she ordered an electroencephalogram (EEG), which records the electrical activity of the brain, at King’s College Hospital, in London, to see if that could explain the seizures.

The scan was carried out on February 9 2023, and a report was sent to Dr Singh stating the results were normal but also outlined Alfred had reported six previous incidents of collapse.

Alfred, of Roehampton Close, Gravesend, was then seen by Dr Singh on April 18, 2023, but was discharged.

When questioned, the consultant said she had not looked at the ECG before his appointment and had not read the report in its entirety so did not know Alfred had an extensive history of collapse.

She told the court if she had known about the other episodes, not including those in September and November, she would have investigated further.

Expert witness Dr Luke Starling, who leads the Inherited Arrhythmia Service at Great Ormond Street Hospital, in London, said “there was ample opportunity” for Alfred to be diagnosed with an inherited arrhythmia.

He told the court the ECGs were clearly “extremely abnormal” and showed a “remarkably” prolonged QT interval which should have been picked up and led to a referral to a cardiologist.

Dr Starling added there was “no doubt” Alfred would have been prescribed beta blockers, medication which slows down the heart, which would have stopped him from having any further seizures.

Giving evidence, he said: “There were so many red flags. If he was on beta blockers and taking them as instructed he would have been protected and not gone on to have an event.”

The cardiologist told the court he would have expected Alfred to have been referred to a specialist when he was first admitted to A&E as he collapsed after exercise.

He explained the youngster would have been diagnosed with long QT syndrome - a condition that is triggered by surges of adrenaline like exercise or stress and causes seizures and sudden death.

Dr Starling said: “This was a significant event. In my opinion, it is not normal and warranted a further referral and I would have expected and accepted a referral.”

Summing up, Ms Wood added: “It was the first opportunity to have been investigated further and put on medication that meant he would have survived.

“All [hospital visits] were missed opportunities by the trust to diagnose or point Alfred in the right direction to be diagnosed with long QT syndrome.

“If he had, it was quite clear that he would have been commenced on beta blockers. Beta blockers would have significantly reduced the risk of a fatal arrhythmia.

“It would have protected him from having the event he went on to have on August 30.

“There was a failure. The use of beta blockers would have prevented Alfred’s death.”

She concluded his cause of death was sudden arrhythmic death and provided a narrative conclusion.

It read: “Alfred died as a consequence of a fatal cardiac arrhythmia which had not been diagnosed at the time of his death despite a number of opportunities for medical staff to investigate his symptoms and refer him to specialist treatment.”

Ms Wood did recognise the Dartford and Gravesham NHS Trust had made several changes in its practice to avoid such an event happening again.

She added: “The trust has taken lots of steps which might be a comfort to Alfred’s mother at least someone else might not be in this position going forward.”

The court was told any child who is admitted to A&E after collapsing is given an ECG no matter their medical history and a specific form has been created so doctors sign off every aspect of the results to ensure it is looked at in detail.

The trust said it has also reviewed all paediatric cases which presented similar symptoms from the last two years to check if more investigations were needed.

A spokesperson for the trust added: “We deeply regret that we did not meet the standards of care Alfred deserved.

“We fully accept the coroner’s conclusion that there was more than one opportunity to diagnose the cause of his faints, and we did not act as we should have.

“We offer our heartfelt condolences to Alfred’s family and recognise the pain this has caused them.

“As a trust, we are committed to learning from this and ensuring there is real, lasting change - embedding these lessons into practice and strengthening our culture to improve the safety and experience of all our patients and their families.”

Following the hearing, Alfred’s mum Omolade Akinola, said she hopes his story will improve the care for other children.

She added: “I struggle to find the words to describe the devastation I feel over Alfred’s death. He was a wonderful and loving son and I felt blessed that he was my boy. Life without him will never be the same again.

“While time has moved on since Alfred’s death it has stood still for me. Having so many unanswered questions regarding his death has just added to the hurt and pain I wake with each day.

“The inquest and reliving what happened has been particularly distressing, but at least it has given me answers.

“Alfred was taken from me far too soon. He had his life ahead of me and I will never get over losing him in the way I did.”

Katy Daws, medical negligence solicitor, at Irwin Mitchell who represented Ms Akinola, added: “Omolade remains devastated by Alfred’s death and the extremely tragic nature of it.

“Understandably she has had a number of questions and concerns about the care Alfred received in the lead-up to his death and whether more could have been done to help him.

“Sadly, the inquest heard worrying evidence around missed opportunities.

“While we are pleased to have been able to secure the answers Omolade deserves, it is now vital that lessons are learned to uphold patient safety.”