A Queensland coroner has recommended that medical staff pay more attention to how much parents know about their child's illness after a young boy died following a severe asthma attack.
Coroner James McDougall largely cleared the Mater Children's Hospital over the 2014 death of a nine-year-old boy but said the child's parents weren't sufficiently educated about his illness.
Gold Coast boy Hunter Marr died on January 6, 2014, a day after he was released from hospital, where he had been admitted on January 2 with breathing difficulties.
Mr McDougall found the boy died from an acute episode of asthma which became increasingly resistant to ventolin.
He said Hunter's discharge from hospital was clinically appropriate but he thought Mr and Mrs Marr's lack of acceptance of their son's asthma diagnosis should have caused concern.
"It is apparent on the evidence that a number of flags were missed or not appropriately handed on, the most important being the Marrs' lack of acceptance that Hunter had asthma and repeated evidence of Hunter being brought to hospital at later than optimal times," he said.
"Although this is an assessment that is made with the benefit of hindsight, the Marrs were not sufficiently educated about the serious and unpredictable nature of asthma."
Hunter's parents told an inquest last November he had never been formally diagnosed with asthma and they didn't consider him asthmatic.
However Mr McDougall said Hunter had been treated for the condition a number of times in the past and had been using ventolin occasionally in the three-and-a-half years before his death.
Mr McDougall said it was unknown why the Marrs' wouldn't believe or accept the diagnosis.
He said in future such cases must be "flagged, documented, escalated and addressed as a matter of urgency".
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