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An oversight by hospital staff contributed to the death of a nine-year-old.
A coroner will now write to Medway NHS Foundation Trust highlighting her concerns.
Luke Jackson, who lived with Becker muscular dystrophy, has been described as a "cheeky little boy" by his heartbroken mum Becky.
In a tribute following an inquest this week, she said his passing had left a "huge void".
The hearing held at Archbishop's Palace, Maidstone , heard how Luke was taken to Medway Maritime Hospital, Gillingham , on December 6.
Mrs Jackson and husband Adam explained how she woke to see her son's bedside monitor, which shows heart rate and oxygen levels, as zero.
She then noticed his foot-attached oximeter clip was hanging, before hitting an emergency button and calling for help.
Luke had suffered for five days with diarrhoea and vomiting and a cough for two days prior to being admitted.
On arrival, tests revealed his potassium levels were dangerously low – between 1.9 and 2.3, when a normal level is considered to be around 3.5 to five.
Realising he was in cardiac arrest, the Medway team, including a paediatric consultant, performed CPR before deciding to send him to the intensive care unit at Evelina Children's Hospital in London.
Dr Shelley Riphagen, who later treated him there, informed his parents he would not wake from his condition and the decision was made to put him into palliative care. He died just under a week later.
Assistant coroner Sonia Hayes heard evidence from Medway hospital's paediatric consultant Dr Richard Patey, who explained how in his plan for Luke it was outlined he should be given potassium to stop his depleting levels and lower the risk of cardiac arrest.
However, for some reason these requests weren't done, something which Dr Patey admitted was an oversight.
Evidence from Dr Riphagen explained how children with muscular dystrophy struggle more than others to replenish their levels of potassium as the body's natural storage for it is in the muscles.
She explained how Luke's vomiting and diarrhoea had seen his potassium levels become dangerously low.
There were some concerns from his parents about the diagnosis of his muscular dystrophy with them concerned he may actually have Duchenne muscular dystrophy, which is a more severe type of Beckers.
However, Ms Hayes said on the balance of probability after hearing evidence from multiple clinicians, Luke had Beckers, but even if he had the more severe condition, it wouldn't have contributed to his death.
"He was a cheeky little boy with a wicked sense of humour who loved Mr Tumble, swimming, playing on a trampoline and listening to Adele"
She recorded a narrative verdict, outlining how a lack of communication among the hospital staff and poor management of Luke's potassium levels led to his death.
She made a section 28 ruling, meaning she will write a report to the hospital in an attempt to prevent similar deaths occurring in future.
Speaking after the inquest, Mrs Jackson, of Allhallows, Hoo , said: "Luke had a difficult start but enjoyed life regardless.
"He was a cheeky little boy with a wicked sense of humour who loved Mr Tumble, swimming, playing on a trampoline and listening to Adele.
"He had a big personality that has left a huge void to all those that knew and loved him. He will be greatly missed. The family would like to thank all who helped with his care."
Luke, who attended Abbey Court Special School, Strood , and had a sister Tilly, three, died on December 12 – eight days after being admitted to hospital.
Responding to the coroner's findings, Medway NHS Foundation Trust chief executive James Devine said: “This is a very sad and distressing matter for Luke’s parents and all the staff involved in his care; we would like to offer our sincere condolences to his family for their tragic loss.
“The trust has carried out a thorough investigation into the circumstances and we have already put in place new processes in the paediatric department to avoid any recurrence of a similar outcome for other young patients with complex medical needs.
“We will also carefully consider the further concerns which the coroner will articulate in her formal recommendation in order to further reduce risk and improve care for all young patients presenting at the hospital with similar needs and presenting conditions.”
