The death of a nine-year-old Jewish chess champion could have been prevented if he had not been sent home from hospital, a coroner has ruled.
Michael Uriely who played for Barnet Knights Chess Club, died of an asthma attack five days after leaving the Royal Free Hospital in north London in 2015.
Doctors failed to diagnose his condition as chronic in the months before his death.
A coroner has ruled that if he had been given a high dose of steroids in hospital "it's unlikely he would have died".
Dr Shirley Radcliffe, said when Michael was admitted to hospital twice within 24 hours, "alarm bells should have begun to ring".
She told Westminster Coroner's Court : "The opportunity was lost to recognise this as a serious problem - the history and signs were there to be seen and understood.
"But sadly it wasn't recognised and he was discharged essentially on the same treatment he had been on."
Michael's parents, Ayelet and Roy Uriely took him to hospital when he suffered a violent coughing and vomiting episode on August 18 2015.
The attack left him struggling to breathe but he was allowed to go home where he suffered another attack and was taken back to A&E, the inquest heard.
The second time he was kept in overnight but medics failed to diagnose his chronic condition despite two internal investigations.
He was released from hospital the following day and died from an asthma attack on August 25.
At the time of his death the nine-year-old had been competing in the Mindsports Olympiad, an international competition which includes chess.
Following Michael’s death, the hospital appointed two specialist respiratory clinicians, and implemented a new strategy for dealing with children with asthma.
His parents said Michael, who was diagnosed with asthma when he was two, was "an extraordinary boy, both in personality and intelligence
"He doted on his younger twin sisters, who adored him, and always joined in with their games".
The inquest heard seven other children in London have died from asthma since his death.
