Jacob Owczarek died at Bassetlaw Hospital in April last year, having been taken there on two previous occasions with sepsis and acute kidney infection pyelonephritis.
The kidney infection was originally treated, but the youngster was not given antibiotics after his discharge, to reduce the risk of further infection.
During Jacob’s third visit to the hospital, showing similar symptoms, he died.
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An inquest into his death, conducted in April 2021, found evidence of chronic kidney scarring, infection, and a severe urinary obstruction at the time of his death.
The coroner said that if scans had been conducted while he was alive, it is likely he would not have died.
In her report, Assistant Coroner for Nottinghamshire Dr Elizabeth Didcock said the hospital’s neglect contributed to Jacob’s death.
Now she has written to Doncaster and Bassetlaw Teaching Hospitals NHS Trust, which runs Bassetlaw Hospital, calling for action.
In a report sent to the trust’s chief executive, she said the hospital’s continued low compliance with paediatric screening tools is a “matter of concern”.
This low compliance, the report states, has been an issue highlighted at the trust “repeatedly in reports over the last five years”.
Dr Didcock also called for the trust to address why the child was not reviewed by a responsible or named consultant before his earlier discharge.
She said: “[Jacob] had presented on two previous occasions unwell with sepsis from the urinary tract.
“The seriousness of the infection on the second presentation was not recognised, and he was allowed home.
“The investigations arranged to look for underlying structural abnormalities of the renal tract were not reviewed in life, and therefore Jacob was never referred for surgical treatment to relieve his obstructed renal tract.
“There were systemic failings in his care, that remain in my view despite a serious incident investigation undertaken, and action plan completed, by the trust.”
The trust must respond to the coroner by September 29 outlining its action plan, forming part of her prevention of future deaths report.
The letter was also sent to the Care Quality Commission (CQC), with the coroner requesting a visit after September 29 to review the trust’s compliance with paediatric sepsis screening.
In response to Jacob’s death, the hospital trust apologised to the boy’s family.
David Purdue, chief nurse and deputy chief executive at the trust, says an investigation took place following the death and “significant changes” have been made.
He added: “I wish to extend my deepest sympathies and condolences to Jacob’s parents as well as their friends, family and loved ones.
“We acknowledge that our processes were not sufficiently robust and accept that this is likely to have made a difference to Jacob and his family. For this, I am very sorry.”