A coroner has raised concerns after a three-year-old boy died "earlier than he would otherwise have done" had multiple medical practitioners spotted he was unwell.

Jaxon Olivera died in March 2025 as a result of leukaemia, which had been diagnosed three days before at St Peter's Hospital in Chertsey, Surrey.

Coroner Dr Karen Henderson wrote that a nurse, a GP and an A&E doctor failed to notice liver problems that could have led to an earlier diagnosis.

The emergency department doctor "has been supported and guided on the learning arising from this case", the hospital said.

In a prevention of future deaths report following an inquest in April, Henderson wrote that not recognising Jaxon's liver condition following multiple consultations between 20 and 23 March "led to a delay in the diagnosis of the leukaemia".

The Surrey coroner said it was "not possible" to say if an earlier diagnosis "would ultimately have prevented Jaxon's death" but the delay did "materially contribute" to him dying earlier.

An advanced nurse practitioner, at a clinic run by North West Surrey Integrated Care Services (NICS), was the first to assess the three-year-old, who had a fever and had been vomiting for several days.

The nurse had "no paediatric nursing qualifications, nor any hospital based paediatric nursing experience" and was "unable to demonstrate how to properly examine an abdomen".

The coroner said she was concerned that such medics were "not sufficiently able or experienced" to assess patients such as Jaxon.

The boy's parents took him to St Peter's Hospital two days later where he was reviewed by a GP at an urgent treatment centre which is run by NCIS.

"The GP had no post-graduate qualifications in paediatrics and undertook a sub-optimal abdominal examination," the coroner wrote.

The following day, Jaxon was taken to the hospital's emergency department and seen by a doctor with "no previous experience in ward-based paediatrics".

His parents "were not listened to, nor were their concerns acted upon", and they did not know the doctor was not a paediatrician, according to the coroner.

The doctor discharged Jaxon within 90 minutes. His parents brought him back 12 hours later with septic shock and he was diagnosed with leukaemia.

He was transferred to a London hospital for chemotherapy but "further treatment was considered futile" and he died on 27 March.

St Peter's Hospital said doctors of that grade are now typically only sent to the children's emergency department "during hours of direct consultant cover" and are told not to discharge paediatric patients without senior approval.

The department had updated its standard operating procedure, the hospital wrote to the coroner, and was in discussions about introducing clearer badges for medical staff depicting their roles.

A spokesperson for NICS said it took the findings "extremely seriously" and was "committed to providing safe, high-quality patient care".

"We have reviewed our clinical practices, reinforced training on paediatric examinations and strengthened our protocols and referral pathways," they said.

In its response to the coroner, NICS wrote that it had "robust systems in place that accord with national guidance" to ensure that staff were competent to assess paediatric patients.

NHS England said that "concerns raised about Jaxon's care have been listened to and reflected upon".

Health minister Karin Smyth wrote that UK doctors were expected to meet General Medical Council's professional standards and that the Nursing and Midwifery Council was considering additional regulation of advanced practitioners.

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