Health professionals missed a number of chances to save a young boy who died from a rare genetic disease, an inquest has found.
A coronial inquest into the death of Sunshine Coast boy Tom Olive has identified several opportunities to diagnose his condition before his sudden death.
The four-year-old went into cardiac arrest at Nambour Hospital on August 25, 2010, and was unable to be resuscitated.
The findings from a March inquest at Maroochydore were delivered in Brisbane on Tuesday and said Tom died from severe rhabdomyolysis, or muscle breakdown, caused by a gene mutation.
Tom's was the first recorded case of the disease in Australia.
Deputy State Coroner John Lock noted the child saw several doctors in the 12 months prior for symptoms including dark urine and muscle pain, but tests showed no abnormalities.
On June 30, 2010, less than a month before his death, the child was taken to Nambour Hospital unable to walk and suffering back pain, but he was discharged after doctors could find nothing wrong.
Mr Lock said contrary results from two urine tests could have raised a red flag, but their significance was not considered.
Also, a letter to Tom's GP suggesting a follow-up test was never passed on.
When the child was rushed to hospital on the morning of August 25 with muscle pain and lethargy from a severe episode of rhabdomyolysis, it was probably already too late.
"In my experience, where there are negative medical outcomes, there is often evidence of poor communication that contributes," Mr Lock wrote in his findings.
"There is evidence of such poor communication in this case, resulting in some missed opportunities to diagnose that Tom was suffering from rhabdomyolysis.
"That being said, any capacity to make a diagnosis of rhabdomyolysis was compounded by Tom having a virtually unknown underlying condition and most of the time displaying atypical symptoms."
The coroner noted the hospital has changed its procedures for discharge letters and reviewing pathology results but said it was important the principles were adhered to.
"It should not require a policy for obvious good, sensible practice to occur," he said.
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